why are problem solving skills important in nursing

The Value of Critical Thinking in Nursing

• How Nurses Use Critical Thinking
• How to Improve Critical Thinking
• Common Mistakes

Some experts describe a person’s ability to question belief systems, test previously held assumptions, and recognize ambiguity as evidence of critical thinking. Others identify specific skills that demonstrate critical thinking, such as the ability to identify problems and biases, infer and draw conclusions, and determine the relevance of information to a situation.

Nicholas McGowan, BSN, RN, CCRN, has been a critical care nurse for 10 years in neurological trauma nursing and cardiovascular and surgical intensive care. He defines critical thinking as “necessary for problem-solving and decision-making by healthcare providers. It is a process where people use a logical process to gather information and take purposeful action based on their evaluation.”

“This cognitive process is vital for excellent patient outcomes because it requires that nurses make clinical decisions utilizing a variety of different lenses, such as fairness, ethics, and evidence-based practice,” he says.

How Do Nurses Use Critical Thinking?

Successful nurses think beyond their assigned tasks to deliver excellent care for their patients. For example, a nurse might be tasked with changing a wound dressing, delivering medications, and monitoring vital signs during a shift. However, it requires critical thinking skills to understand how a difference in the wound may affect blood pressure and temperature and when those changes may require immediate medical intervention.

Nurses care for many patients during their shifts. Strong critical thinking skills are crucial when juggling various tasks so patient safety and care are not compromised.

Jenna Liphart Rhoads, Ph.D., RN, is a nurse educator with a clinical background in surgical-trauma adult critical care, where critical thinking and action were essential to the safety of her patients. She talks about examples of critical thinking in a healthcare environment, saying:

“Nurses must also critically think to determine which patient to see first, which medications to pass first, and the order in which to organize their day caring for patients. Patient conditions and environments are continually in flux, therefore nurses must constantly be evaluating and re-evaluating information they gather (assess) to keep their patients safe.”

The COVID-19 pandemic created hospital care situations where critical thinking was essential. It was expected of the nurses on the general floor and in intensive care units. Crystal Slaughter is an advanced practice nurse in the intensive care unit (ICU) and a nurse educator. She observed critical thinking throughout the pandemic as she watched intensive care nurses test the boundaries of previously held beliefs and master providing excellent care while preserving resources.

“Nurses are at the patient’s bedside and are often the first ones to detect issues. Then, the nurse needs to gather the appropriate subjective and objective data from the patient in order to frame a concise problem statement or question for the physician or advanced practice provider,” she explains.

Top 5 Ways Nurses Can Improve Critical Thinking Skills

We asked our experts for the top five strategies nurses can use to purposefully improve their critical thinking skills.

Case-Based Approach

Slaughter is a fan of the case-based approach to learning critical thinking skills.

In much the same way a detective would approach a mystery, she mentors her students to ask questions about the situation that help determine the information they have and the information they need. “What is going on? What information am I missing? Can I get that information? What does that information mean for the patient? How quickly do I need to act?”

Consider forming a group and working with a mentor who can guide you through case studies. This provides you with a learner-centered environment in which you can analyze data to reach conclusions and develop communication, analytical, and collaborative skills with your colleagues.

Practice Self-Reflection

Rhoads is an advocate for self-reflection. “Nurses should reflect upon what went well or did not go well in their workday and identify areas of improvement or situations in which they should have reached out for help.” Self-reflection is a form of personal analysis to observe and evaluate situations and how you responded.

This gives you the opportunity to discover mistakes you may have made and to establish new behavior patterns that may help you make better decisions. You likely already do this. For example, after a disagreement or contentious meeting, you may go over the conversation in your head and think about ways you could have responded.

It’s important to go through the decisions you made during your day and determine if you should have gotten more information before acting or if you could have asked better questions.

During self-reflection, you may try thinking about the problem in reverse. This may not give you an immediate answer, but can help you see the situation with fresh eyes and a new perspective. How would the outcome of the day be different if you planned the dressing change in reverse with the assumption you would find a wound infection? How does this information change your plan for the next dressing change?

Develop a Questioning Mind

McGowan has learned that “critical thinking is a self-driven process. It isn’t something that can simply be taught. Rather, it is something that you practice and cultivate with experience. To develop critical thinking skills, you have to be curious and inquisitive.”

To gain critical thinking skills, you must undergo a purposeful process of learning strategies and using them consistently so they become a habit. One of those strategies is developing a questioning mind. Meaningful questions lead to useful answers and are at the core of critical thinking .

However, learning to ask insightful questions is a skill you must develop. Faced with staff and nursing shortages , declining patient conditions, and a rising number of tasks to be completed, it may be difficult to do more than finish the task in front of you. Yet, questions drive active learning and train your brain to see the world differently and take nothing for granted.

It is easier to practice questioning in a non-stressful, quiet environment until it becomes a habit. Then, in the moment when your patient’s care depends on your ability to ask the right questions, you can be ready to rise to the occasion.

Practice Self-Awareness in the Moment

Critical thinking in nursing requires self-awareness and being present in the moment. During a hectic shift, it is easy to lose focus as you struggle to finish every task needed for your patients. Passing medication, changing dressings, and hanging intravenous lines all while trying to assess your patient’s mental and emotional status can affect your focus and how you manage stress as a nurse .

Staying present helps you to be proactive in your thinking and anticipate what might happen, such as bringing extra lubricant for a catheterization or extra gloves for a dressing change.

By staying present, you are also better able to practice active listening. This raises your assessment skills and gives you more information as a basis for your interventions and decisions.

Use a Process

As you are developing critical thinking skills, it can be helpful to use a process. For example:

• Ask questions.
• Gather information.
• Implement a strategy.
• Evaluate the results.
• Consider another point of view.

These are the fundamental steps of the nursing process (assess, diagnose, plan, implement, evaluate). The last step will help you overcome one of the common problems of critical thinking in nursing — personal bias.

Common Critical Thinking Pitfalls in Nursing

Your brain uses a set of processes to make inferences about what’s happening around you. In some cases, your unreliable biases can lead you down the wrong path. McGowan places personal biases at the top of his list of common pitfalls to critical thinking in nursing.

“We all form biases based on our own experiences. However, nurses have to learn to separate their own biases from each patient encounter to avoid making false assumptions that may interfere with their care,” he says. Successful critical thinkers accept they have personal biases and learn to look out for them. Awareness of your biases is the first step to understanding if your personal bias is contributing to the wrong decision.

New nurses may be overwhelmed by the transition from academics to clinical practice, leading to a task-oriented mindset and a common new nurse mistake ; this conflicts with critical thinking skills.

“Consider a patient whose blood pressure is low but who also needs to take a blood pressure medication at a scheduled time. A task-oriented nurse may provide the medication without regard for the patient’s blood pressure because medication administration is a task that must be completed,” Slaughter says. “A nurse employing critical thinking skills would address the low blood pressure, review the patient’s blood pressure history and trends, and potentially call the physician to discuss whether medication should be withheld.”

Fear and pride may also stand in the way of developing critical thinking skills. Your belief system and worldview provide comfort and guidance, but this can impede your judgment when you are faced with an individual whose belief system or cultural practices are not the same as yours. Fear or pride may prevent you from pursuing a line of questioning that would benefit the patient. Nurses with strong critical thinking skills exhibit:

• Learn from their mistakes and the mistakes of other nurses
• Look forward to integrating changes that improve patient care
• Treat each patient interaction as a part of a whole
• Evaluate new events based on past knowledge and adjust decision-making as needed
• Solve problems with their colleagues
• Are self-confident
• Acknowledge biases and seek to ensure these do not impact patient care

An Essential Skill for All Nurses

Critical thinking in nursing protects patient health and contributes to professional development and career advancement. Administrative and clinical nursing leaders are required to have strong critical thinking skills to be successful in their positions.

By using the strategies in this guide during your daily life and in your nursing role, you can intentionally improve your critical thinking abilities and be rewarded with better patient outcomes and potential career advancement.

Frequently Asked Questions About Critical Thinking in Nursing

How are critical thinking skills utilized in nursing practice.

Nursing practice utilizes critical thinking skills to provide the best care for patients. Often, the patient’s cause of pain or health issue is not immediately clear. Nursing professionals need to use their knowledge to determine what might be causing distress, collect vital information, and make quick decisions on how best to handle the situation.

How does nursing school develop critical thinking skills?

Nursing school gives students the knowledge professional nurses use to make important healthcare decisions for their patients. Students learn about diseases, anatomy, and physiology, and how to improve the patient’s overall well-being. Learners also participate in supervised clinical experiences, where they practice using their critical thinking skills to make decisions in professional settings.

Do only nurse managers use critical thinking?

Nurse managers certainly use critical thinking skills in their daily duties. But when working in a health setting, anyone giving care to patients uses their critical thinking skills. Everyone — including licensed practical nurses, registered nurses, and advanced nurse practitioners —needs to flex their critical thinking skills to make potentially life-saving decisions.

Meet Our Contributors

Crystal Slaughter, DNP, APRN, ACNS-BC, CNE

Crystal Slaughter is a core faculty member in Walden University’s RN-to-BSN program. She has worked as an advanced practice registered nurse with an intensivist/pulmonary service to provide care to hospitalized ICU patients and in inpatient palliative care. Slaughter’s clinical interests lie in nursing education and evidence-based practice initiatives to promote improving patient care.

Jenna Liphart Rhoads, Ph.D., RN

Jenna Liphart Rhoads is a nurse educator and freelance author and editor. She earned a BSN from Saint Francis Medical Center College of Nursing and an MS in nursing education from Northern Illinois University. Rhoads earned a Ph.D. in education with a concentration in nursing education from Capella University where she researched the moderation effects of emotional intelligence on the relationship of stress and GPA in military veteran nursing students. Her clinical background includes surgical-trauma adult critical care, interventional radiology procedures, and conscious sedation in adult and pediatric populations.

Nicholas McGowan, BSN, RN, CCRN

Nicholas McGowan is a critical care nurse with 10 years of experience in cardiovascular, surgical intensive care, and neurological trauma nursing. McGowan also has a background in education, leadership, and public speaking. He is an online learner who builds on his foundation of critical care nursing, which he uses directly at the bedside where he still practices. In addition, McGowan hosts an online course at Critical Care Academy where he helps nurses achieve critical care (CCRN) certification.

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Critical Thinking in Nursing: Tips to Develop the Skill

4 min read • February, 09 2024

Critical thinking in nursing helps caregivers make decisions that lead to optimal patient care. In school, educators and clinical instructors introduced you to critical-thinking examples in nursing. These educators encouraged using learning tools for assessment, diagnosis, planning, implementation, and evaluation.

Nurturing these invaluable skills continues once you begin practicing. Critical thinking is essential to providing quality patient care and should continue to grow throughout your nursing career until it becomes second nature. 

What Is Critical Thinking in Nursing?

Critical thinking in nursing involves identifying a problem, determining the best solution, and implementing an effective method to resolve the issue using clinical decision-making skills.

Reflection comes next. Carefully consider whether your actions led to the right solution or if there may have been a better course of action.

Remember, there's no one-size-fits-all treatment method — you must determine what's best for each patient.

How Is Critical Thinking Important for Nurses? 

As a patient's primary contact, a nurse is typically the first to notice changes in their status. One example of critical thinking in nursing is interpreting these changes with an open mind. Make impartial decisions based on evidence rather than opinions. By applying critical-thinking skills to anticipate and understand your patients' needs, you can positively impact their quality of care and outcomes.

Elements of Critical Thinking in Nursing

To assess situations and make informed decisions, nurses must integrate these specific elements into their practice:

• Clinical judgment. Prioritize a patient's care needs and make adjustments as changes occur. Gather the necessary information and determine what nursing intervention is needed. Keep in mind that there may be multiple options. Use your critical-thinking skills to interpret and understand the importance of test results and the patient’s clinical presentation, including their vital signs. Then prioritize interventions and anticipate potential complications. 
• Patient safety. Recognize deviations from the norm and take action to prevent harm to the patient. Suppose you don't think a change in a patient's medication is appropriate for their treatment. Before giving the medication, question the physician's rationale for the modification to avoid a potential error. 
• Communication and collaboration. Ask relevant questions and actively listen to others while avoiding judgment. Promoting a collaborative environment may lead to improved patient outcomes and interdisciplinary communication. 
• Problem-solving skills. Practicing your problem-solving skills can improve your critical-thinking skills. Analyze the problem, consider alternate solutions, and implement the most appropriate one. Besides assessing patient conditions, you can apply these skills to other challenges, such as staffing issues . 

How to Develop and Apply Critical-Thinking Skills in Nursing

Critical-thinking skills develop as you gain experience and advance in your career. The ability to predict and respond to nursing challenges increases as you expand your knowledge and encounter real-life patient care scenarios outside of what you learned from a textbook. 

Here are five ways to nurture your critical-thinking skills:

• Be a lifelong learner. Continuous learning through educational courses and professional development lets you stay current with evidence-based practice . That knowledge helps you make informed decisions in stressful moments.  
• Practice reflection. Allow time each day to reflect on successes and areas for improvement. This self-awareness can help identify your strengths, weaknesses, and personal biases to guide your decision-making.
• Open your mind. Don't assume you're right. Ask for opinions and consider the viewpoints of other nurses, mentors , and interdisciplinary team members.
• Use critical-thinking tools. Structure your thinking by incorporating nursing process steps or a SWOT analysis (strengths, weaknesses, opportunities, and threats) to organize information, evaluate options, and identify underlying issues.
• Be curious. Challenge assumptions by asking questions to ensure current care methods are valid, relevant, and supported by evidence-based practice .

Critical thinking in nursing is invaluable for safe, effective, patient-centered care. You can successfully navigate challenges in the ever-changing health care environment by continually developing and applying these skills.

Images sourced from Getty Images

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• Research article
• Open access
• Published: 07 October 2020

Impact of social problem-solving training on critical thinking and decision making of nursing students

• Soleiman Ahmady 1 &
• Sara Shahbazi   ORCID: orcid.org/0000-0001-8397-6233 2 , 3  

BMC Nursing volume  19 , Article number:  94 ( 2020 ) Cite this article

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The complex health system and challenging patient care environment require experienced nurses, especially those with high cognitive skills such as problem-solving, decision- making and critical thinking. Therefore, this study investigated the impact of social problem-solving training on nursing students’ critical thinking and decision-making.

This study was quasi-experimental research and pre-test and post-test design and performed on 40 undergraduate/four-year students of nursing in Borujen Nursing School/Iran that was randomly divided into 2 groups; experimental ( n  = 20) and control (n = 20). Then, a social problem-solving course was held for the experimental group. A demographic questionnaire, social problem-solving inventory-revised, California critical thinking test, and decision-making questionnaire was used to collect the information. The reliability and validity of all of them were confirmed. Data analysis was performed using SPSS software and independent sampled T-test, paired T-test, square chi, and Pearson correlation coefficient.

The finding indicated that the social problem-solving course positively affected the student’ social problem-solving and decision-making and critical thinking skills after the instructional course in the experimental group ( P  < 0.05), but this result was not observed in the control group ( P  > 0.05).

Conclusions

The results showed that structured social problem-solving training could improve cognitive problem-solving, critical thinking, and decision-making skills. Considering this result, nursing education should be presented using new strategies and creative and different ways from traditional education methods. Cognitive skills training should be integrated in the nursing curriculum. Therefore, training cognitive skills such as problem- solving to nursing students is recommended.

Peer Review reports

Continuous monitoring and providing high-quality care to patients is one of the main tasks of nurses. Nurses’ roles are diverse and include care, educational, supportive, and interventional roles when dealing with patients’ clinical problems [ 1 , 2 ].

Providing professional nursing services requires the cognitive skills such as problem-solving, decision-making and critical thinking, and information synthesis [ 3 ].

Problem-solving is an essential skill in nursing. Improving this skill is very important for nurses because it is an intellectual process which requires the reflection and creative thinking [ 4 ].

Problem-solving skill means acquiring knowledge to reach a solution, and a person’s ability to use this knowledge to find a solution requires critical thinking. The promotion of these skills is considered a necessary condition for nurses’ performance in the nursing profession [ 5 , 6 ].

Managing the complexities and challenges of health systems requires competent nurses with high levels of critical thinking skills. A nurse’s critical thinking skills can affect patient safety because it enables nurses to correctly diagnose the patient’s initial problem and take the right action for the right reason [ 4 , 7 , 8 ].

Problem-solving and decision-making are complex and difficult processes for nurses, because they have to care for multiple patients with different problems in complex and unpredictable treatment environments [ 9 , 10 ].

Clinical decision making is an important element of professional nursing care; nurses’ ability to form effective clinical decisions is the most significant issue affecting the care standard. Nurses build 2 kinds of choices associated with the practice: patient care decisions that affect direct patient care and occupational decisions that affect the work context or teams [ 11 , 12 , 13 , 14 , 15 , 16 ].

The utilization of nursing process guarantees the provision of professional and effective care. The nursing process provides nurses with the chance to learn problem-solving skills through teamwork, health management, and patient care. Problem-solving is at the heart of nursing process which is why this skill underlies all nursing practices. Therefore, proper training of this skill in an undergraduate nursing program is essential [ 17 ].

Nursing students face unique problems which are specific to the clinical and therapeutic environment, causing a lot of stresses during clinical education. This stress can affect their problem- solving skills [ 18 , 19 , 20 , 21 ]. They need to promote their problem-solving and critical thinking skills to meet the complex needs of current healthcare settings and should be able to respond to changing circumstances and apply knowledge and skills in different clinical situations [ 22 ]. Institutions should provide this important opportunity for them.

Despite, the results of studies in nursing students show the weakness of their problem-solving skills, while in complex health environments and exposure to emerging diseases, nurses need to diagnose problems and solve them rapidly accurately. The teaching of these skills should begin in college and continue in health care environments [ 5 , 23 , 24 ].

It should not be forgotten that in addition to the problems caused by the patients’ disease, a large proportion of the problems facing nurses are related to the procedures of the natural life of their patients and their families, the majority of nurses with the rest of health team and the various roles defined for nurses [ 25 ].

Therefore, in addition to above- mentioned issues, other ability is required to deal with common problems in the working environment for nurses, the skill is “social problem solving”, because the term social problem-solving includes a method of problem-solving in the “natural context” or the “real world” [ 26 , 27 ]. In reviewing the existing research literature on the competencies and skills required by nursing students, what attracts a lot of attention is the weakness of basic skills and the lack of formal and systematic training of these skills in the nursing curriculum, it indicates a gap in this area [ 5 , 24 , 25 ]. In this regard, the researchers tried to reduce this significant gap by holding a formal problem-solving skills training course, emphasizing the common social issues in the real world of work. Therefore, this study was conducted to investigate the impact of social problem-solving skills training on nursing students’ critical thinking and decision-making.

Setting and sample

This quasi-experimental study with pretest and post-test design was performed on 40 undergraduate/four-year nursing students in Borujen nursing school in Shahrekord University of Medical Sciences. The periods of data collection were 4 months.

According to the fact that senior students of nursing have passed clinical training and internship programs, they have more familiarity with wards and treatment areas, patients and issues in treatment areas and also they have faced the problems which the nurses have with other health team personnel and patients and their families, they have been chosen for this study. Therefore, this study’s sampling method was based on the purpose, and the sample size was equal to the total population. The whole of four-year nursing students participated in this study and the sample size was 40 members. Participants was randomly divided in 2 groups; experimental ( n  = 20) and control (n = 20).

The inclusion criteria to take part in the present research were students’ willingness to take part, studying in the four-year nursing, not having the record of psychological sickness or using the related drugs (all based on their self-utterance).

Intervention

At the beginning of study, all students completed the demographic information’ questionnaire. The study’s intervening variables were controlled between the two groups [such as age, marital status, work experience, training courses, psychological illness, psychiatric medication use and improving cognitive skills courses (critical thinking, problem- solving, and decision making in the last 6 months)]. Both groups were homogeneous in terms of demographic variables ( P  > 0.05). Decision making and critical thinking skills and social problem solving of participants in 2 groups was evaluated before and 1 month after the intervention.

All questionnaires were anonymous and had an identification code which carefully distributed by the researcher.

To control the transfer of information among the students of two groups, the classification list of students for internships, provided by the head of nursing department at the beginning of semester, was used.

Furthermore, the groups with the odd number of experimental group and the groups with the even number formed the control group and thus were less in contact with each other.

The importance of not transferring information among groups was fully described to the experimental group. They were asked not to provide any information about the course to the students of the control group.

Then, training a course of social problem-solving skills for the experimental group, given in a separate course and the period from the nursing curriculum and was held in 8 sessions during 2 months, using small group discussion, brainstorming, case-based discussion, and reaching the solution in small 4 member groups, taking results of the social problem-solving model as mentioned by D-zurilla and gold fried [ 26 ]. The instructor was an assistant professor of university and had a history of teaching problem-solving courses. This model’ stages are explained in Table  1 .

All training sessions were performed due to the model, and one step of the model was implemented in each session. In each session, the teacher stated the educational objectives and asked the students to share their experiences in dealing to various workplace problems, home and community due to the topic of session. Besides, in each session, a case-based scenario was presented and thoroughly analyzed, and students discussed it.

Instruments

In this study, the data were collected using demographic variables questionnaire and social problem- solving inventory – revised (SPSI-R) developed by D’zurilla and Nezu (2002) [ 26 ], California critical thinking skills test- form B (CCTST; 1994) [ 27 , 28 ] and decision-making questionnaire.

SPSI-R is a self - reporting tool with 52 questions ranging from a Likert scale (1: Absolutely not – 5: very much).

The minimum score maybe 25 and at a maximum of 125, therefore:

The score 25 and 50: weak social problem-solving skills.

The score 50–75: moderate social problem-solving skills.

The score higher of 75: strong social problem-solving skills.

The reliability assessed by repeated tests is between 0.68 and 0.91, and its alpha coefficient between 0.69 and 0.95 was reported [ 26 ]. The structural validity of questionnaire has also been confirmed. All validity analyses have confirmed SPSI as a social problem - solving scale.

In Iran, the alpha coefficient of 0.85 is measured for five factors, and the retest reliability coefficient was obtained 0.88. All of the narratives analyzes confirmed SPSI as a social problem- solving scale [ 29 ].

California critical thinking skills test- form B(CCTST; 1994): This test is a standard tool for assessing the basic skills of critical thinking at the high school and higher education levels (Facione & Facione, 1992, 1998) [ 27 ].

This tool has 34 multiple-choice questions which assessed analysis, inference, and argument evaluation. Facione and Facione (1993) reported that a KR-20 range of 0.65 to 0.75 for this tool is acceptable [ 27 ].

In Iran, the KR-20 for the total scale was 0.62. This coefficient is acceptable for questionnaires that measure the level of thinking ability of individuals.

After changing the English names of this questionnaire to Persian, its content validity was approved by the Board of Experts.

The subscale analysis of Persian version of CCTST showed a positive high level of correlation between total test score and the components (analysis, r = 0.61; evaluation, r = 0.71; inference, r = 0.88; inductive reasoning, r = 0.73; and deductive reasoning, r = 0.74) [ 28 ].

A decision-making questionnaire with 20 questions was used to measure decision-making skills. This questionnaire was made by a researcher and was prepared under the supervision of a professor with psychometric expertise. Five professors confirmed the face and content validity of this questionnaire. The reliability was obtained at 0.87 which confirmed for 30 students using the test-retest method at a time interval of 2 weeks. Each question had four levels and a score from 0.25 to 1. The minimum score of this questionnaire was 5, and the maximum score was 20 [ 30 ].

Statistical analysis

For analyzing the applied data, the SPSS Version 16, and descriptive statistics tests, independent sample T-test, paired T-test, Pearson correlation coefficient, and square chi were used. The significant level was taken P  < 0.05.

The average age of students was 21.7 ± 1.34, and the academic average total score was 16.32 ± 2.83. Other demographic characteristics are presented in Table  2 .

None of the students had a history of psychiatric illness or psychiatric drug use. Findings obtained from the chi-square test showed that there is not any significant difference between the two groups statistically in terms of demographic variables.

The mean scores in social decision making, critical thinking, and decision-making in whole samples before intervention showed no significant difference between the two groups statistically ( P  > 0.05), but showed a significant difference after the intervention ( P  < 0.05) (Table  3 ).

Scores in Table  4 showed a significant positive difference before and after intervention in the “experimental” group ( P  < 0.05), but this difference was not seen in the control group ( P  > 0.05).

Among the demographic variables, only a positive relationship was seen between marital status and decision-making skills (r = 0.72, P  < 0.05).

Also, the scores of critical thinking skill’ subgroups and social problem solving’ subgroups are presented in Tables  5 and 6 which showed a significant positive difference before and after intervention in the “experimental” group (P < 0.05), but this difference was not seen in the control group ( P  > 0.05).

In the present study conducted by some studies, problem-solving and critical thinking and decision-making scores of nursing students are moderate [ 5 , 24 , 31 ].

The results showed that problem-solving skills, critical thinking, and decision-making in nursing students were promoted through a social problem-solving training course. Unfortunately, no study has examined the effect of teaching social problem-solving skills on nursing students’ critical thinking and decision-making skills.

Altun (2018) believes that if the values of truth and human dignity are promoted in students, it will help them acquire problem-solving skills. Free discussion between students and faculty on value topics can lead to the development of students’ information processing in values. Developing self-awareness increases students’ impartiality and problem-solving ability [ 5 ]. The results of this study are consistent to the results of present study.

Erozkan (2017), in his study, reported there is a significant relationship between social problem solving and social self-efficacy and the sub-dimensions of social problem solving [ 32 ]. In the present study, social problem -solving skills training has improved problem -solving skills and its subdivisions.

The results of study by Moshirabadi (2015) showed that the mean score of total problem-solving skills was 89.52 ± 21.58 and this average was lower in fourth-year students than other students. He explained that education should improve students’ problem-solving skills. Because nursing students with advanced problem-solving skills are vital to today’s evolving society [ 22 ]. In the present study, the results showed students’ weakness in the skills in question, and holding a social problem-solving skills training course could increase the level of these skills.

Çinar (2010) reported midwives and nurses are expected to use problem-solving strategies and effective decision-making in their work, using rich basic knowledge.

These skills should be developed throughout one’s profession. The results of this study showed that academic education could increase problem-solving skills of nursing and midwifery students, and final year students have higher skill levels [ 23 ].

Bayani (2012) reported that the ability to solve social problems has a determining role in mental health. Problem-solving training can lead to a level upgrade of mental health and quality of life [ 33 ]; These results agree with the results obtained in our study.

Conducted by this study, Kocoglu (2016) reported nurses’ understanding of their problem-solving skills is moderate. Receiving advice and support from qualified nursing managers and educators can enhance this skill and positively impact their behavior [ 31 ].

Kashaninia (2015), in her study, reported teaching critical thinking skills can promote critical thinking and the application of rational decision-making styles by nurses.

One of the main components of sound performance in nursing is nurses’ ability to process information and make good decisions; these abilities themselves require critical thinking. Therefore, universities should envisage educational and supportive programs emphasizing critical thinking to cultivate their students’ professional competencies, decision-making, problem-solving, and self-efficacy [ 34 ].

The study results of Kirmizi (2015) also showed a moderate positive relationship between critical thinking and problem-solving skills [ 35 ].

Hong (2015) reported that using continuing PBL training promotes reflection and critical thinking in clinical nurses. Applying brainstorming in PBL increases the motivation to participate collaboratively and encourages teamwork. Learners become familiar with different perspectives on patients’ problems and gain a more comprehensive understanding. Achieving these competencies is the basis of clinical decision-making in nursing. The dynamic and ongoing involvement of clinical staff can bridge the gap between theory and practice [ 36 ].

Ancel (2016) emphasizes that structured and managed problem-solving training can increase students’ confidence in applying problem-solving skills and help them achieve self-confidence. He reported that nursing students want to be taught in more innovative ways than traditional teaching methods which cognitive skills training should be included in their curriculum. To this end, university faculties and lecturers should believe in the importance of strategies used in teaching and the richness of educational content offered to students [ 17 ].

The results of these recent studies are adjusted with the finding of recent research and emphasize the importance of structured teaching cognitive skills to nurses and nursing students.

Based on the results of this study on improving critical thinking and decision-making skills in the intervention group, researchers guess the reasons to achieve the results of study in the following cases:

In nursing internationally, problem-solving skills (PS) have been introduced as a key strategy for better patient care [ 17 ]. Problem-solving can be defined as a self-oriented cognitive-behavioral process used to identify or discover effective solutions to a special problem in everyday life. In particular, the application of this cognitive-behavioral methodology identifies a wide range of possible effective solutions to a particular problem and enhancement the likelihood of selecting the most effective solution from among the various options [ 27 ].

In social problem-solving theory, there is a difference among the concepts of problem-solving and solution implementation, because the concepts of these two processes are different, and in practice, they require different skills.

In the problem-solving process, we seek to find solutions to specific problems, while in the implementation of solution, the process of implementing those solutions in the real problematic situation is considered [ 25 , 26 ].

The use of D’zurilla and Goldfride’s social problem-solving model was effective in achieving the study results because of its theoretical foundations and the usage of the principles of cognitive reinforcement skills. Social problem solving is considered an intellectual, logical, effort-based, and deliberate activity [ 26 , 32 ]; therefore, using this model can also affect other skills that need recognition.

In this study, problem-solving training from case studies and group discussion methods, brainstorming, and activity in small groups, was used.

There are significant educational achievements in using small- group learning strategies. The limited number of learners in each group increases the interaction between learners, instructors, and content. In this way, the teacher will be able to predict activities and apply techniques that will lead students to achieve high cognitive taxonomy levels. That is, confront students with assignments and activities that force them to use cognitive processes such as analysis, reasoning, evaluation, and criticism.

In small groups, students are given the opportunity to the enquiry, discuss differences of opinion, and come up with solutions. This method creates a comprehensive understanding of the subject for the student [ 36 ].

According to the results, social problem solving increases the nurses’ decision-making ability and critical thinking regarding identifying the patient’s needs and choosing the best nursing procedures. According to what was discussed, the implementation of this intervention in larger groups and in different levels of education by teaching other cognitive skills and examining their impact on other cognitive skills of nursing students, in the future, is recommended.

Social problem- solving training by affecting critical thinking skills and decision-making of nursing students increases patient safety. It improves the quality of care because patients’ needs are better identified and analyzed, and the best solutions are adopted to solve the problem.

In the end, the implementation of this intervention in larger groups in different levels of education by teaching other cognitive skills and examining their impact on other cognitive skills of nursing students in the future is recommended.

Study limitations

This study was performed on fourth-year nursing students, but the students of other levels should be studied during a cohort from the beginning to the end of course to monitor the cognitive skills improvement.

The promotion of high-level cognitive skills is one of the main goals of higher education. It is very necessary to adopt appropriate approaches to improve the level of thinking. According to this study results, the teachers and planners are expected to use effective approaches and models such as D’zurilla and Goldfride social problem solving to improve problem-solving, critical thinking, and decision-making skills. What has been confirmed in this study is that the routine training in the control group should, as it should, has not been able to improve the students’ critical thinking skills, and the traditional educational system needs to be transformed and reviewed to achieve this goal.

Availability of data and materials

The datasets used and analyzed during the present study are available from the corresponding author on reasonable request.

Abbreviations

California critical thinking skills test

Social problem-solving inventory – revised

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Acknowledgments

This article results from research project No. 980 approved by the Research and Technology Department of Shahrekord University of Medical Sciences. We would like to appreciate to all personnel and students of the Borujen Nursing School. The efforts of all those who assisted us throughout this research.

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SA and SSH conceptualized the study, developed the proposal, coordinated the project, completed initial data entry and analysis, and wrote the report. SSH conducted the statistical analyses. SA and SSH assisted in writing and editing the final report. All authors read and approved the final manuscript.

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Relationship Between the Problem-Solving Skills and Empathy Skills of Operating Room Nurses

AY, Fatma 1* ; POLAT, Şehrinaz; KASHIMI, Tennur

1 PhD, RN, Assistant Professor, Faculty of Health Sciences, Department of Midwifery, Istanbul University-Cerrahpaşa, Turkey

2 PhD, RN, Directorate of Nursing Services, Hospital of Faculty of Medicine, Istanbul University, Turkey

3 MS, RN, Director, Operating Room, Hospital of Faculty of Medicine, Istanbul University, Turkey.

Accepted for publication: January 21, 2019

*Address correspondence to: Fatma AY, No.25, Dr. Tevfik Saglam Street, Dr. Zuhuratbaba District, Bakirkoy, Istanbul 34147, Turkey. Tel: +90 212 4141500 ext. 40140; Fax: +90 212 4141515; E-mail: [email protected]

The authors declare no conflicts of interest.

Cite this article as: Ay, F., Polat, Ş., & Kashimi, T. (2019). Relationship between the problem-solving skills and empathy skills of operating room nurses. The Journal of Nursing Research , 28 (2), e75. https://doi.org/10.1097/jnr.0000000000000357

This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY) , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background 

The use of empathy in problem solving and communication is a focus of nursing practice and is of great significance in raising the quality of patient care.

Purpose 

The purposes of this study are to investigate the relationship between problem solving and empathy among operating room nurses and to explore the factors that relate to these two competencies.

Methods 

This is a cross-sectional, descriptive study. Study data were gathered using a personal information form, the Interpersonal Problem Solving Inventory, and the Basic Empathy Scale ( N = 80). Descriptive and comparative statistics were employed to evaluate the study data.

Results 

Age, marital status, and career length were not found to affect the subscale scores of cognitive empathy ( p > .05). A negative correlation was found between the subscale scores for “diffidence” and “cognitive empathy.” Moreover, the emotional empathy scores of the graduate nurses were higher than those of the master's/doctorate degree nurses to a degree that approached significance ( p = .078). Furthermore, emotional empathy levels were found to decrease as the scores for insistent/persistent approach, lack of self-confidence, and educational level increased ( p < .05). The descriptive characteristics of the participating nurses were found not to affect their problem-solving skills.

Conclusions/Implications for Practice 

Problem solving is a focus of nursing practice and of great importance for raising the quality of patient care. Constructive problem-solving skills affect cognitive empathy skills. Educational level and career length were found to relate negatively and level of self-confidence was found to relate positively with level of cognitive empathy. Finally, lower empathy scores were associated with difficult working conditions in operating rooms, intense stress, and high levels of potential stress-driven conflicts between workers in work settings.

Introduction

Healthcare institutions are where individuals seek remedies to their health problems. These institutions face problems, which relate to both employees and care recipients. These problems may occur spontaneously and require immediate solution. Moreover, these problems require that the preferred remedies be adapted to address the unique nature of both organizational circumstances and individual requirements. Therefore, it is important that nurses, who are a major component of the healthcare system, have problem-solving skills.

Operating rooms are complex, high-risk environments with intense levels of stress that require rapid judgment making and fast implementation of appropriate decisions to increase patients' chances of survival ( Kanan, 2011 ; Jeon, Lakanmaa, Meretoja, & Leino-Kilpi, 2017 ). Furthermore, aseptic principles may never be compromised, and a high level of coordination and cooperation among team members should be maintained in these areas ( Kanan, 2011 ; Sandelin & Gustafsson, 2015 ). The members of a surgical team may vary in the operating room ( Sandelin & Gustafsson, 2015 ; Sonoda, Onozuka, & Hagihara, 2018 ). Under these difficult conditions, time management and workload are important stress factors for nurses ( Happell et al., 2013 ; Suresh, Matthews, & Coyne, 2013 ). At the same time, operating room nurses are legally responsible for the nature and quality of the healthcare service received by patients before, during, and after their surgical intervention ( Kanan, 2011 ). The American Nurses Association defines a nurse as “the healthcare professional establishing, coordinating and administering the care while applying the nursing process in an aim to meet the identified physiological, psychological, sociocultural and spiritual needs of patients who are potentially at the risk of jeopardized protective reflexes or self-care ability because of surgery or invasive intervention” ( Association of periOperative Registered Nurses, 2015 ).

Problem solving is the most critical aspect of the nursing practice. The fact that nursing requires mental and abstract skills, such as identifying individual needs and finding appropriate remedies, was first stated in 1960s. In 1960s, the nursing theorists Abdellah, Orem, and Levin emphasized the mental aspect of nursing. They argued that the most critical requirement of nurses in the clinical field is the ability to decide on and plan the right action and that nursing care should be founded on a sound knowledge base ( Taşci, 2005 ).

The World Health Organization has stated that “taking measures and applying a problem-solving approach to provide appropriate care is one of the compulsory competencies of nurses” ( Taşci, 2005 ). Thus, enhancing the problem-solving skills of nurses is of great importance in raising the quality of patient care ( Taylor, 2000 ; Yu & Kirk, 2008 ). On the other hand, Bagnal (1981) argued that people with problem-solving skills need to be equipped with personal traits including innovation, clear manifestation of preferences and decisions, having a sense of responsibility, flexible thinking, courage and adventurousness, ability to show distinct ideas, self-confidence, a broad area of interest, acting rationally and objectively, creativity, productivity, and critical perspective (as cited in Çam & Tümkaya, 2008 ).

To provide the best surgical care to a patient, team members must work together effectively ( Sonoda et al., 2018 ). One of the most important factors affecting the quality of healthcare service delivery is effective communication between healthcare professionals and healthcare recipients, with empathy forming the basis for effective communication.

Because of the intrinsic nature of the nursing profession, nurses should have empathy skills. Thus, empathy is the essence of the nursing profession ( Fields et al., 2004 ; Vioulac, Aubree, Massy, & Untas, 2016 ). A review of resources in the literature on problem solving reveals that gathering problem-related data is the first major step toward determining the root causes of a problem. In this respect, empathy is an important skill that helps properly identify a problem. On the basis of the definition of empathy, sensing another person's feelings and thoughts and placing oneself in his or her position or feeling from within his or her frame of reference should work to improve one's problem-solving skills, particularly those skills related to social problem solving ( Taşci, 2005 ; Topçu, Baker, & Aydin, 2010 ; Vioulac et al., 2016 ). It is possible to explain empathic content emotionally as well as cognitively. Emotional empathy (EE) means feeling the emotions of another person and providing the most appropriate response based on his or her emotional state. This is very important in patient–nurse communications. Cognitive empathy (CE) is the ability to recognize the feelings of another without experiencing those feelings yourself ( de Kemp, Overbeek, de Wied, Engels, & Scholte, 2007 ).

Gender, age, level of education, marital status, years of work, duration working at current institution, and problem-solving situations have been shown in the literature not to affect the problem-solving or empathy skills of nurses ( Abaan & Altintoprak, 2005 ; Kelleci & Gölbaşi, 2004 ; Yu & Kirk, 2008 ). Empathy is especially critical to the quality of nursing care and is an essential component of any form of caring relationship. The findings in the literature regarding empathy among nurses are inconsistent ( Yu & Kirk, 2008 ), and no findings in the literature address the relationship between problem-solving skills and empathy skills in operating room nurses.

Today, the healthcare system demands that nurses use their professional knowledge to handle patient problems and needs in flexible and creative ways. Problem solving is a primary focus of the nursing practice and is of great importance to raising the quality of patient care ( Kelleci & Gölbaşi, 2004 ; Yu & Kirk, 2008 ). Enhancing the problem-solving and empathy skills of nurses may be expected to facilitate their identification of the sources of problems encountered during the delivery of healthcare services and their resolution of these problems.

The purposes of this study are to investigate the relationship between problem solving and empathy in operating room nurses and to explore the factors related to these two competencies.

Study Model and Hypotheses

This study is a cross-sectional and descriptive study. The three hypotheses regarding the relationships between the independent variables are as follows:

• H1: Sociodemographic characteristics affect problem-solving skills.
• H2: Sociodemographic characteristics affect level of empathy.
• H3: Problem-solving skills are positively and significantly correlated with empathy.

Study Population and Sample

The study was conducted during the period of May–June 2015 at three hospitals affiliated with Istanbul University. The study population consisted of 121 nurses who were currently working in the operating rooms of these hospitals. The study sample consisted of the 80 nurses who volunteered to participate and answered all of the questions on the inventory.

Data Collection Tool

Study data were gathered using a personal information form, the Interpersonal Problem Solving Inventory (IPSI), and the Basic Empathy Scale.

Personal information form

This questionnaire, created by the researchers, is composed of 10 questions on the age, gender, educational background, organization and department, position, and organizational and professional functions of the respondent.

Interpersonal problem solving inventory

The IPSI, developed and validated by Çam and Tümkaya (2008) , was used in this study. The Cronbach's α internal consistency coefficients of the IPSI subscales were previously evaluated at between .67 and .91. The IPSI includes 50 items, all of which are scored on a 5-point Likert scale, with 1 = strictly inappropriate and 5 = fully appropriate . The lack of self-confidence (LSC) subscale assesses lack of confidence in problem solving. The constructive problem solving (CPS) subscale assesses emotions, thoughts, and behaviors that contribute to the effective and constructive solution of interpersonal problems. The negative approach to the problem subscale assesses intensely the negative emotions and thoughts such as helplessness, pessimism, and disappointment that are experienced when an interpersonal problem is encountered. The abstaining from responsibility subscale assesses failure to take responsibility for solving the problem. The persistent approach (PA) subscale assesses self-assertive/persistent thoughts and behaviors in solving problems encountered in interpersonal relationships. A high score on a subscale indicates a high interpersonal-problem-solving capability for that subscale category ( Çam & Tümkaya, 2008 ). A high score on the negative approach to the problem subscale indicates a higher likelihood of experiencing intense negative feelings and thoughts such as helplessness, pessimism, and sadness when encountering a problem. A high score on CPS indicates that the respondent will show more of the emotions, thoughts, and behaviors that contribute to the problem in an effective and constructive way. A low level of self-confidence indicates that the respondent will exhibit low self-confidence toward effectively resolving a problem. A high score on the abstaining from responsibility subscale indicates a high inclination to assume responsibility to resolve a problem ( Table 1 ). The high level of insistent approach indicates that the participant is more willing to solve problems ( Çam & Tümkaya, 2008 ). In this study, the Cronbach's α reliability coefficients were .901, .899, .763, .679, and .810, respectively.

Basic empathy skill scale

The Basic Empathy Skill Scale was developed by Jolliffe and Farrington (2006) and validated by Topçu et al. (2010) in Turkish. It is a 5-Likert scale (1 = s trictly disagree and 5 = strictly agree ) consisting of 20 items, of which nine measure CE and 11 measure EE. The Cronbach's α coefficients that were calculated for the reliability study range between .76 and .80. The lowest possible scores are 9 and 45 and the highest possible scores are 11 and 55 for the CE and EE subscales, respectively. A high score on the CE subscale indicates that the CE level is high, and a high score on the EE subscale indicates that the EE level is high ( Topçu et al., 2010 ). The two subscales of the Basic Empathy Skill Scale have been found to be highly reliable. The Cronbach's α reliability coefficients in this study were .782 for the CE subscale and .649 for the EE subscale.

Data Collection

The study was conducted between May and June 2015 at three hospitals affiliated with Istanbul University. The researcher explained the study to those nurses who agreed to participate. The questionnaire form was distributed to the participants, the purpose of the investigation was clarified, and permission to use participant data was obtained. The participants completed the questionnaire on their own, and the completed questionnaires were collected afterward. The time required to complete the questionnaire was 15–20 minutes in total.

Evaluation of Data

Number Cruncher Statistical System 2007 (Kaysville, UT, USA) software was used to perform statistical analysis. To compare the quantitative data, in addition to using descriptive statistical methods (mean, standard deviation, median, frequency, ratio, minimum, maximum), the Student t test was used to compare the parameters with the regular distribution in the two groups and the Mann–Whitney U test was used to compare the parameters without normal distribution in the two groups. In addition, a one-way analysis of variance test was used to compare three or more groups with normal distribution, and a Kruskal–Wallis test was used to compare three or more groups without normal distribution. Pearson's correlation analysis and Spearman's correlation analysis were used to evaluate the relationships among the parameters. Finally, linear regression analysis was employed to evaluate multivariate data. Significance was determined by a p value of < .05.

Ethical Considerations

Ethical conformity approval was obtained from the Non-Interventional Clinical Research Ethics Board at Istanbul Medipol University (108400987-165, issued on March 30, 2015). Written consent was obtained from the administrations of the participating hospitals. Furthermore, the informed consent of nurses who volunteered to participate was obtained. Permission to use the abovementioned scales that were used in this study as data collection tools was obtained via e-mail from their original authors.

Eighty nurses (97.5% female, n = 78; 2.5% male, n = 2) were enrolled as participants. The age of participants ranged between 24 and 64 (mean = 37.56 ± 8.12) years, mean years of professional nursing experience was 15.84 ± 8.30, and mean years working in the current hospital was 13.19 ± 8.23. Other descriptive characteristics for the participants are provided in Table 2 .

A comparison of scale subdimension scores revealed a negative and statistically significant correlation at a level of 22.3%. Statistical significance was reached only between the LSC subscale and the CE subscale ( r = −.223, p = .047; Table 3 ). Thus, a higher LSC score was associated with a lower CE score.

Comparisons between participants' descriptive characteristics and subdimension scores on the problem-solving skill scale revealed no significant differences. Thus, demographic characteristics such as age, educational background, and career length were found to have no influence on problem-solving skills ( p > .05; Table 4 ).

Age, marital status, and professional career length were not found to affect the CE and EE subscale scores, with no statistically significant correlations found between the two subscales ( p > .05; Table 4 ). However, the EE scores of undergraduate nurses were found to be higher than those of postgraduate nurses, at a level that approached statistical significance ( p = .078). In addition, the average CE scores of nurses who had worked for 1–10 and 11–20 years were higher than those of nurses who had worked for 21 years or more, at a level that approached statistical significance ( p = .066).

A statistically significant difference was found between mean years working in the current hospital and educational background, respectively, and CE scores ( p = .027 and p = .013; Table 4 ). On the basis of paired comparison analysis, the CE scores of participants with 1–10 years of working experience at their current hospital were higher than those with ≥ 21 years of working experience at their current hospital ( p = .027). Also on the basis of paired comparison analysis, the CE score of participants educated to the undergraduate level was found to be higher at a statistically significant level than those educated to the master's/doctorate degree level ( p = .013).

The comparison of problem-solving skill scores by descriptive characteristics revealed no statistically significant difference between subscale scores and the variables of age, marital status, length of professional and organizational career, or educational background ( p > .05). Thus, the descriptive characteristics of the participants did not affect their problem-solving skills.

Regression Analysis of Risk Factors Affecting Cognitive and Empathy Skills

Variables found after univariate analysis to have significance levels of p < .01 were subsequently modeled and evaluated. A regression analysis was conducted to determine the effect on CE skills of educational level, duration of institutional work, CPS level, and self-insecurity level. The explanatory power of this model was 29.9% ( R 2 = .299), and the model was significant ( p < .001). As a result of the analysis, CPS ( p = .006), educational status of graduate ( p < .001), and working for the current hospital for a period of more than 20 years ( p = .004) were found to have a significant and positive influence on the CE score.

A 1-unit increase in the CPS score was found to increase CE skills by 0.139 points (β = 0.139, 95% CI [0.041, 0.237], p < .01). For education, graduate education was found to decrease the CE score by 4.520 points (β = −4.520, 95% CI [−6.986, −2.054], p < .001). For duration working for the current hospital, working for the same institution for a period exceeding 20 years was found to decrease the CE score by 3.429 points (β = −3.429, 95% CI [−5.756, −1.102], p < .05). In addition, a 1-unit increase in the LSC score was found to decrease the CE score by 0.114 points, which did not achieve statistical significance (β = 0.114, 95% CI [−0.325, 0.096], p > .05).

Regression analysis was used to evaluate the effects of education, PA, and LSC on the risk factors affecting EE. As a result of this evaluation, the explanatory power of the model was determined as 15.3% ( R 2 = .153), which was significant despite the low level ( F = 3.388, p = .001). The effects of PA ( p = .021) and educational status ( p = .015) on the EE score were shown through analysis to be statistically significant ( Table 5 ). A 1-unit increase in PA score was found to increase the EE score by 0.323 points (β = 0.323, 95% CI [0.049, 0.596], p < .05). For education, having a graduate education was found to decrease the EE score by 3.989 points (β = −3.989, 95% CI [−7.193, −0.786], p < .05). Moreover, the LSC score was found to be 0.119 points lower than the EE score. However, this result was not statistically significant (β = −0.193, 95% CI [−0.467, 0.080], p > .05). Dummy variables were used in the regression analysis of sociodemographic characteristics (educational status and years working for the current hospital).

This study found that age, marital status, educational background, years of professional working experience, and years working for the current hospital did not affect the problem-solving skills of the participants. In the literature, the findings of several studies indicate that characteristics such as age, educational background, department of service, and career length do not affect the problem-solving skills of nurses ( Abaan & Altintoprak, 2005 ; Kelleci & Gölbaşi, 2004 ; Yu & Kirk, 2008 ), whereas other studies indicate that these variables do affect these skills ( Ançel, 2006 ; Watt-Watson, Garfinkel, Gallop, Stevens, & Streiner, 2000 ; Yu & Kirk, 2008 ). However, beyond these characteristics, some studies have reported a positive correlation between the problem-solving skills of nurses and their educational level, with this correlation mediated by the physical conditions of the workplace, good relationships with colleagues, and educational background ( Yildiz & Güven, 2009 ). These findings suggest that factors affecting the empathy and problem-solving skills of nurses working in operating rooms differ from known and expected factors.

Operating room nurses deliver dynamic nursing care that requires attention and close observation because of the fast turnover of patients. In addition to the problem-solving skills that they use during the patient care process, these nurses must use or operate a myriad of lifesaving technological devices and equipment ( AbuAlRub, 2004 ; Özgür, Yildirim, & Aktaş, 2008 ). The circumstances in which nurses employ their problem-solving skills are generally near-death critical conditions and emergencies. Furthermore, operating rooms are more isolated than other areas of the hospital, which affects nurses who work in operating rooms and intensive care units ( AbuAlRub, 2004 ; Özgür et al., 2008 ).

Communication is a critical factor that affects the delivery of healthcare services. Communication does not only take place between a service recipient and a provider. To establish a teamwork philosophy between employees, it is essential to build effective communication ( Sandelin & Gustafsson, 2015 ). Empathic communication helps enhance the problem-solving skills of nurses as they work to learn about individual experiences ( Kumcağiz, Yilmaz, Çelik, & Avci, 2011 ). Studies in the literature have found that nurses who are satisfied with their relationships with colleagues, physicians, and supervisors have a high level of problem-solving skills ( Abaan & Altintoprak, 2005 ; Kumcağiz et al., 2011 ) and that higher problem-solving skills are associated with a higher level of individual achievement ( Abaan & Altintoprak, 2005 ; Chan, 2001 ). Another finding of this study is that CPS increases the cognitive emphatic level. This may be attributed to constructive problem-solving skills increasing CE, as these skills are associated with feelings, thoughts, and behaviors that contribute to problem resolution.

A review of the literature on empathy and communication skills revealed, as expected, that these skills increased with level of education ( Kumcağiz et al., 2011 ; Vioulac et al., 2016 ). However, a number of studies have reported no significant correlation between age, marital status, and professional working experience and empathy skills or communication abilities in nurses ( Kumcağiz et al., 2011 ; Yu & Kirk, 2008 ).

EE is assumed to be a more intuitive reaction to emotions. Factors that affect EE are nurses working with small patient groups, frequent contact with patient groups, and long periods spent accompanying or being in close contact with patient groups ( Vioulac et al., 2016 ). Studies in the literature have reported no correlation between the empathy skills of nurses and demographic characteristics ( Vioulac et al., 2016 ). This study supports this finding, with the empathy skills of operating room nurses found to be close to the peak value of the scale.

Studies in the literature reveal a positive correlation between empathy and career length ( Watt-Watson et al., 2000 ; Yu & Kirk, 2008 ) as well as a correlation between increased professional experience and lower empathy ( Yu & Kirk, 2008 ). This study found an association between longer periods working for the same hospital and higher levels of education with lower empathy scores. This may be attributed to the difficult working conditions in operating rooms, intense stress, and high level of potential stress-driven conflicts between employees in work settings.

Stress is a major factor that affects the empathy skills and relationship-building abilities of nurses ( Vioulac et al., 2016 ). Nurses are exposed to a wide variety of stressors such as quality of the service, duration of shifts, workload, time pressures, and limited decision-making authority ( Patrick & Lavery, 2007 ; Shimizutani et al., 2008 ; Vioulac et al., 2016 ). In particular, environments evoking a sense of death (e.g., operating rooms) is another factor known to elevate perceived stress ( Ashker, Penprase, & Salman, 2012 ). High stress may lead to negative consequences such as reduced problem-solving abilities ( Zhao, Lei, He, Gu, & Li, 2015 ). Both having a long nursing career and working in stressful environments such as operating rooms may negatively affect empathy and problem-solving skills. However, this study revealed that working for a long period at the current hospital had no influence on problem-solving skills. The low reliability of the scales means that the variance may be high in other samples that are drawn from the same main sample, with the resultant data thus not reflecting the truth.

Low reliability coefficients reduce the significance and value of the results obtained by increasing the standard error of the data ( Şencan, 2005 ). The Cronbach's α of the EE scale used in the study was between .60 and .80 and is highly trustworthy. However, the Cronbach's α value is close to .60 (i.e., .649). This result may elicit suspicion in regression analysis estimates that are done to determine the variables that affect EE. In the correlation analysis, a statistically significant weak correlation was found only between the LSC subdimension and CE. However, the fact that the subscales of empathy and problem-solving skills are significantly related to the regression models may also be related to the reliability levels of the scales.

According to the results of the regression analysis, all of the variables remaining in Model A affected level of low for the CE ( R 2 = .299). Having constructive problem-solving skills ( p = .006), having a high level of education ( p < .001), and working for the current hospital for over 20 years ( p = .004) were found to be significantly related to CE.

Other variables were found to have no significant effect. According to the results of the regression analysis, all of the remaining variables in Model B accounted for a relatively low portion of the EE ( R 2 = .153). When the t test results for the significance of the regression coefficients were examined, it was determined that PA ( p = .021) and educational status ( p = .015) were significant predictors of EE. Other variables had no significant effect ( Table 5 ). The increase in the level of education of nurses may have increased their cognitive and emotional development. Thus, working in the same hospital for over 20 years was found to increase the levels of CE and EE. This result may be because of greater professional experience and regular experience handling numerous, different problems. In addition, the low explanatory power of the models may also be because of the fact that many other arguments that may affect empathy were not modeled. When constant values are fixed and the value of the independent variables entering the regression formula is zero, constant value is the estimated value of the dependent variable. According to findings of this study, sociodemographic characteristics and problem-solving abilities did not affect empathy level, although the CE value was 31.707 and the EE value was 37.024. Repeating this research in larger and different nurse groups may be useful to verify these research results.

Conclusions

The following results were derived from this study: First, constructive problem-solving skills affect CE skills. EE is adversely affected by the PA and LSC. Second, no correlation was found between the demographic characteristics of nurses and their problem-solving skills. Third, as level of education increases, cognitive and emotional levels of empathy decrease.

Duration of time spent working at one's current healthcare institution and educational level were both found to correlate negatively with the CE score. The higher the educational level and PA and the lower the self-confidence of the participants, the lower their EE levels. Finally, higher constructive problem-solving scores were associated with higher CE skills.

Limitations

The major limitation of the study is that it was conducted in the affiliated hospitals of one healthcare organization. The study data were obtained from operating room nurses who currently worked in these hospitals and who volunteered to participate. The conditions of nurses who did not participate in the study cannot be ascertained. A second important limitation is that the data reflect the subjective perceptions and statements of the participants. A third important limitation is that participant characteristics such as trust in management, trust in the institution, burnout, and communication skills were not assessed. For this reason, the effects of these variables on problem-solving and empathy skills remain unknown.

Author Contributions

Study conception and design: SP

Data collection: TK

Data analysis and interpretation: FA, SP

Drafting of the article: FA

Critical revision of the article: FA

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Why Critical Thinking Skills in Nursing Matter (And What You Can Do to Develop Them)

By Hannah Meinke on 07/05/2021

The nursing profession tends to attract those who have natural nurturing abilities, a desire to help others, and a knack for science or anatomy. But there is another important skill that successful nurses share, and it's often overlooked: the ability to think critically.

Identifying a problem, determining the best solution and choosing the most effective method to solve the program are all parts of the critical thinking process. After executing the plan, critical thinkers reflect on the situation to figure out if it was effective and if it could have been done better. As you can see, critical thinking is a transferable skill that can be leveraged in several facets of your life.

But why is it so important for nurses to use? We spoke with several experts to learn why critical thinking skills in nursing are so crucial to the field, the patients and the success of a nurse. Keep reading to learn why and to see how you can improve this skill.

Why are critical thinking skills in nursing important?

You learn all sorts of practical skills in nursing school, like flawlessly dressing a wound, taking vitals like a pro or starting an IV without flinching. But without the ability to think clearly and make rational decisions, those skills alone won’t get you very far—you need to think critically as well.

“Nurses are faced with decision-making situations in patient care, and each decision they make impacts patient outcomes. Nursing critical thinking skills drive the decision-making process and impact the quality of care provided,” says Georgia Vest, DNP, RN and senior dean of nursing at the Rasmussen University School of Nursing.

For example, nurses often have to make triage decisions in the emergency room. With an overflow of patients and limited staff, they must evaluate which patients should be treated first. While they rely on their training to measure vital signs and level of consciousness, they must use critical thinking to analyze the consequences of delaying treatment in each case.

No matter which department they work in, nurses use critical thinking in their everyday routines. When you’re faced with decisions that could ultimately mean life or death, the ability to analyze a situation and come to a solution separates the good nurses from the great ones.

How are critical thinking skills acquired in nursing school?

Nursing school offers a multitude of material to master and upholds high expectations for your performance. But in order to learn in a way that will actually equip you to become an excellent nurse, you have to go beyond just memorizing terms. You need to apply an analytical mindset to understanding course material.

One way for students to begin implementing critical thinking is by applying the nursing process to their line of thought, according to Vest. The process includes five steps: assessment, diagnosis, outcomes/planning, implementation and evaluation.

“One of the fundamental principles for developing critical thinking is the nursing process,” Vest says. “It needs to be a lived experience in the learning environment.”

Nursing students often find that there are multiple correct solutions to a problem. The key to nursing is to select the “the most correct” solution—one that will be the most efficient and best fit for that particular situation. Using the nursing process, students can narrow down their options to select the best one.

When answering questions in class or on exams, challenge yourself to go beyond simply selecting an answer. Start to think about why that answer is correct and what the possible consequences might be. Simply memorizing the material won’t translate well into a real-life nursing setting.

How can you develop your critical thinking skills as a nurse?

As you know, learning doesn’t stop with graduation from nursing school. Good nurses continue to soak up knowledge and continually improve throughout their careers. Likewise, they can continue to build their critical thinking skills in the workplace with each shift.

“To improve your critical thinking, pick the brains of the experienced nurses around you to help you get the mindset,” suggests Eileen Sollars, RN ADN, AAS. Understanding how a seasoned nurse came to a conclusion will provide you with insights you may not have considered and help you develop your own approach.

The chain of command can also help nurses develop critical thinking skills in the workplace.

“Another aid in the development of critical thinking I cannot stress enough is the utilization of the chain of command,” Vest says. “In the chain of command, the nurse always reports up to the nurse manager and down to the patient care aide. Peers and fellow healthcare professionals are not in the chain of command. Clear understanding and proper utilization of the chain of command is essential in the workplace.”

How are critical thinking skills applied in nursing?

“Nurses use critical thinking in every single shift,” Sollars says. “Critical thinking in nursing is a paramount skill necessary in the care of your patients. Nowadays there is more emphasis on machines and technical aspects of nursing, but critical thinking plays an important role. You need it to understand and anticipate changes in your patient's condition.”

As a nurse, you will inevitably encounter a situation in which there are multiple solutions or treatments, and you'll be tasked with determining the solution that will provide the best possible outcome for your patient. You must be able to quickly and confidently assess situations and make the best care decision in each unique scenario. It is in situations like these that your critical thinking skills will direct your decision-making.

Do critical thinking skills matter more for nursing leadership and management positions?

While critical thinking skills are essential at every level of nursing, leadership and management positions require a new level of this ability.

When it comes to managing other nurses, working with hospital administration, and dealing with budgets, schedules or policies, critical thinking can make the difference between a smooth-running or struggling department. At the leadership level, nurses need to see the big picture and understand how each part works together.

A nurse manager , for example, might have to deal with being short-staffed. This could require coaching nurses on how to prioritize their workload, organize their tasks and rely on strategies to keep from burning out. A lead nurse with strong critical thinking skills knows how to fully understand the problem and all its implications.

• How will patient care be affected by having fewer staff?
• What kind of strain will be on the nurses?

Their solutions will take into account all their resources and possible roadblocks.

• What work can be delegated to nursing aids?
• Are there any nurses willing to come in on their day off?
• Are nurses from other departments available to provide coverage?

They’ll weigh the pros and cons of each solution and choose those with the greatest potential.

• Will calling in an off-duty nurse contribute to burnout?
• Was this situation a one-off occurrence or something that could require an additional hire in the long term?

Finally, they will look back on the issue and evaluate what worked and what didn’t. With critical thinking skills like this, a lead nurse can affect their entire staff, patient population and department for the better.

Beyond thinking

You’re now well aware of the importance of critical thinking skills in nursing. Even if you already use critical thinking skills every day, you can still work toward strengthening that skill. The more you practice it, the better you will become and the more naturally it will come to you.

If you’re interested in critical thinking because you’d like to move up in your current nursing job, consider how a Bachelor of Science in Nursing (BSN) could help you develop the necessary leadership skills.

EDITOR’S NOTE: This article was originally published in July 2012. It has since been updated to include information relevant to 2021.

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Making Decisions and Solving Problems

CHAPTER 6 Making Decisions and Solving Problems Rose Aguilar Welch This chapter describes the key concepts related to problem solving and decision making. The primary steps of the problem-solving and decision-making processes, as well as analytical tools used for these processes, are explored. Moreover, strategies for individual or group problem solving and decision making are presented. Objectives •  Apply a decision-making format to list options to solve a problem, identify the pros and cons of each option, rank the options, and select the best option. •  Evaluate the effect of faulty information gathering on a decision-making experience. •  Analyze the decision-making style of a nurse leader/manager. •  Critique resources on the Internet that focus on critical thinking, problem solving, and decision making. Terms to Know autocratic creativity critical thinking decision making democratic optimizing decision participative problem solving satisficing decision The Challenge Vickie Lemmon RN, MSN Director of Clinical Strategies and Operations, WellPoint, Inc., Ventura, California Healthcare managers today are faced with numerous and complex issues that pertain to providing quality services for patients within a resource-scarce environment. Stress levels among staff can escalate when problems are not resolved, leading to a decrease in morale, productivity, and quality service. This was the situation I encountered in my previous job as administrator for California Children Services (CCS). When I began my tenure as the new CCS administrator, staff expressed frustration and dissatisfaction with staffing, workload, and team communications. This was evidenced by high staff turnover, lack of teamwork, customer complaints, unmet deadlines for referral and enrollment cycle times, and poor documentation. The team was in crisis, characterized by in-fighting, blaming, lack of respectful communication, and lack of commitment to program goals and objectives. I had not worked as a case manager in this program. It was hard for me to determine how to address the problems the staff presented to me. I wanted to be fair but thought that I did not have enough information to make immediate changes. My challenge was to lead this team to greater compliance with state-mandated performance measures. What do you think you would do if you were this nurse? Introduction Problem solving and decision making are essential skills for effective nursing practice. Carol Huston (2008) identified “expert decision-making skills” as one of the eight vital leadership competencies for 2020. These processes not only are involved in managing and delivering care but also are essential for engaging in planned change. Myriad technologic, social, political, and economic changes have dramatically affected health care and nursing. Increased patient acuity, shorter hospital stays, shortage of healthcare providers, increased technology, greater emphasis on quality and patient safety, and the continuing shift from inpatient to ambulatory and home health care are some of the changes that require nurses to make rational and valid decisions. Moreover, increased diversity in patient populations, employment settings, and types of healthcare providers demands efficient and effective decision making and problem solving. More emphasis is now placed on involving patients in decision making and problem solving and using multidisciplinary teams to achieve results. Nurses must possess the basic knowledge and skills required for effective problem solving and decision making. These competencies are especially important for nurses with leadership and management responsibilities. Definitions Problem solving and decision making are not synonymous terms. However, the processes for engaging in both processes are similar. Both skills require critical thinking, which is a high-level cognitive process, and both can be improved with practice. Decision making is a purposeful and goal-directed effort that uses a systematic process to choose among options. Not all decision making begins with a problem situation. Instead, the hallmark of decision making is the identification and selection of options or alternatives. Problem solving, which includes a decision-making step, is focused on trying to solve an immediate problem, which can be viewed as a gap between “what is” and “what should be.” Effective problem solving and decision making are predicated on an individual’s ability to think critically. Although critical thinking has been defined in numerous ways, Scriven and Paul (2007) refer to it as “ the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action.” Effective critical thinkers are self-aware individuals who strive to improve their reasoning abilities by asking “why,” “what,” or “how.” A nurse who questions why a patient is restless is thinking critically. Compare the analytical abilities of a nurse who assumes a patient is restless because of anxiety related to an upcoming procedure with those of a nurse who asks if there could be another explanation and proceeds to investigate possible causes. It is important for nurse leaders and managers to assess staff members’ ability to think critically and enhance their knowledge and skills through staff-development programs, coaching, and role modeling. Establishing a positive and motivating work environment can enhance attitudes and dispositions to think critically. Creativity is essential for the generation of options or solutions. Creative individuals can conceptualize new and innovative approaches to a problem or issue by being more flexible and independent in their thinking. It takes just one person to plant a seed for new ideas to generate . The model depicted in Figure 6-1 demonstrates the relationship among related concepts such as professional judgment, decision making, problem solving, creativity, and critical thinking. Sound clinical judgment requires critical or reflective thinking. Critical thinking is the concept that interweaves and links the others. An individual, through the application of critical-thinking skills, engages in problem solving and decision making in an environment that can promote or inhibit these skills. It is the nurse leader’s and manager’s task to model these skills and promote them in others. FiGURE 6-1 Problem-solving and decision-making model. Decision Making This section presents an overview of concepts related to decision models, decision-making styles, factors affecting decision making, group decision making (advantages and challenges), and strategies and tools. The phases of the decision-making process include defining objectives, generating options, identifying advantages and disadvantages of each option, ranking the options, selecting the option most likely to achieve the predefined objectives, implementing the option, and evaluating the result. Box 6-1 contains a form that can be used to complete these steps. BOX 6-1    Decision-Making Format Objective: _____________________________________ Options Advantages Disadvantages Ranking                                 Add more rows as necessary. Rank priority of options, with “1” being most preferred. Select the best option. Implementation plan: ______________________________________________________________________________ Evaluation plan: __________________________________________________________________________________ A poor-quality decision is likely if the objectives are not clearly identified or if they are inconsistent with the values of the individual or organization. Lewis Carroll illustrates the essential step of defining the goal, purpose, or objectives in the following excerpt from Alice’s Adventures in Wonderland: One day Alice came to a fork in the road and saw a Cheshire Cat in a tree. “Which road do I take?” she asked. His response was a question: “Where do you want to go?” “I don’t know,” Alice answered. “Then,” said the cat, “it doesn’t matter.” Decision Models The decision model that a nurse uses depends on the circumstances. Is the situation routine and predictable or complex and uncertain? Is the goal of the decision to make a decision conservatively that is just good enough or one that is optimal? If the situation is fairly routine, nurse leaders and managers can use a normative or prescriptive approach. Agency policy, standard procedures, and analytical tools can be applied to situations that are structured and in which options are known. If the situation is subjective, non-routine, and unstructured or if outcomes are unknown or unpredictable, the nurse leader and manager may need to take a different approach. In this case, a descriptive or behavioral approach is required. More information will need to be gathered to address the situation effectively. Creativity, experience, and group process are useful in dealing with the unknown. In the business world, Camillus described complex problems that are difficult to describe or resolve as “wicked” (as cited in Huston, 2008 ). This term is apt in describing the issues that nurse leaders face. In these situations, it is especially important for nurse leaders to seek expert opinion and involve key stakeholders. Another strategy is satisficing. In this approach, the decision maker selects the solution that minimally meets the objective or standard for a decision. It allows for quick decisions and may be the most appropriate when time is an issue. Optimizing is a decision style in which the decision maker selects the option that is best, based on an analysis of the pros and cons associated with each option. A better decision is more likely using this approach, although it does take longer to arrive at a decision. For example, a nursing student approaching graduation is contemplating seeking employment in one of three acute care hospitals located within a 40-mile radius of home. The choices are a medium-size, not-for-profit community hospital; a large, corporate-owned hospital; and a county facility. A satisficing decision might result if the student nurse picked the hospital that offered a decent salary and benefit packet or the one closest to home. However, an optimizing decision is more likely to occur if the student nurse lists the pros and cons of each acute care hospital being considered such as salary, benefits, opportunities for advancement, staff development, and mentorship programs. Decision-Making Styles The decision-making style of a nurse manager is similar to the leadership style that the manager is likely to use. A manager who leans toward an autocratic style may choose to make decisions independent of the input or participation of others. This has been referred to as the “decide and announce” approach, an authoritative style. On the other hand, a manager who uses a democratic or participative approach to management involves the appropriate personnel in the decision-making process. It is imperative for managers to involve nursing personnel in making decisions that affect patient care. One mechanism for doing so is by seeking nursing representation on various committees or task forces. Participative management has been shown to increase work performance and productivity, decrease employee turnover, and enhance employee satisfaction. Any decision style can be used appropriately or inappropriately. Like the tenets of situational leadership theory, the situation and circumstances should dictate which decision-making style is most appropriate. A Code Blue is not the time for managers to democratically solicit volunteers for chest compressions! The autocratic method results in more rapid decision making and is appropriate in crisis situations or when groups are likely to accept this type of decision style. However, followers are generally more supportive of consultative and group approaches. Although these approaches take more time, they are more appropriate when conflict is likely to occur, when the problem is unstructured, or when the manager does not have the knowledge or skills to solve the problem. Exercise 6-1 Interview colleagues about their most preferred decision-making model and style. What barriers or obstacles to effective decision making have your colleagues encountered? What strategies are used to increase the effectiveness of the decisions made? Based on your interview, is the style effective? Why or why not? Factors Affecting Decision Making Numerous factors affect individuals and groups in the decision-making process. Tanner (2006) conducted an extensive review of the literature to develop a Clinical Judgment Model. Out of the research, she concluded that five principle factors influence decision making. (See the Literature Perspective below.) Literature Perspective Resource: Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45 (6), 204-211. Tanner engaged in an extensive review of 200 studies focusing on clinical judgment and clinical decision making to derive a model of clinical judgment that can be used as a framework for instruction. The first review summarized 120 articles and was published in 1998. The 2006 article reviewed an additional 71 studies published since 1998. Based on an analysis of the entire set of articles, Tanner proposed five conclusions which are listed below. The reader is referred to the article for detailed explanation of each of the five conclusions. The author considers clinical judgment as a “problem-solving activity.” She notes that the terms “clinical judgment,” “problem solving,” “decision making,” and “critical thinking” are often used interchangeably. For the purpose of aiding in the development of the model, Tanner defined clinical judgment as actions taken based on the assessment of the patient’s needs. Clinical reasoning is the process by which nurses make their judgments (e.g., the decision-making process of selecting the most appropriate option) ( Tanner, 2006 , p. 204): 1.  Clinical judgments are more influenced by what nurses bring to the situation than the objective data about the situation at hand. 2.  Sound clinical judgment rests to some degree on knowing the patient and his or her typical pattern of responses, as well as an engagement with the patient and his or her concerns. 3.  Clinical judgments are influenced by the context in which the situation occurs and the culture of the nursing care unit. 4.  Nurses use a variety of reasoning patterns alone or in combination. 5.  Reflection on practice is often triggered by a breakdown in clinical judgment and is critical for the development of clinical knowledge and improvement in clinical reasoning. The Clinical Judgment Model developed through the review of the literature involves four steps that are similar to problem-solving and decision-making steps described in this chapter. The model starts with a phase called “Noticing.” In this phase, the nurse comes to expect certain responses resulting from knowledge gleaned from similar patient situations, experiences, and knowledge. External factors influence nurses in this phase such as the complexity of the environment and values and typical practices within the unit culture. The second phase of the model is “Interpreting,” during which the nurse understands the situation that requires a response. The nurse employs various reasoning patterns to make sense of the issue and to derive an appropriate action plan. The third phase is “Responding,” during which the nurse decides on the best option for handling the situation. This is followed by the fourth phase, “Reflecting,” during which the nurse assesses the patient’s responses to the actions taken. Tanner emphasized that “reflection-in-action” and “reflection-on-action” are major processes required in the model. Reflection-in-action is real-time reflection on the patient’s responses to nursing action with modifications to the plan based on the ongoing assessment. On the other hand, reflection-on-action is a review of the experience, which promotes learning for future similar experiences. Nurse educators and managers can employ this model with new and experienced nurses to aid in understanding thought processes involved in decision making. As Tanner (2006) so eloquently concludes, “If we, as nurse educators, help our students understand and develop as moral agents, advance their clinical knowledge through expert guidance and coaching, and become habitual in reflection-on-practice, they will have learned to think like a nurse” ( p. 210 ). Implications for Practice Nurse educators and managers can employ this model with new and experienced nurses to aid in understanding thought processes involved in decision making. For example, students and practicing nurses can be encouraged to maintain reflective journals to record observations and impressions from clinical experiences. In clinical post-conferences or staff development meetings, the nurse educator and manager can engage them in applying to their lived experiences the five conclusions Tanner proposed. The ultimate goal of analyzing their decisions and decision-making processes is to improve clinical judgment, problem-solving, decision-making, and critical-thinking skills. Internal and external factors can influence how the situation is perceived. Internal factors include variables such as the decision maker’s physical and emotional state, personal philosophy, biases, values, interests, experience, knowledge, attitudes, and risk-seeking or risk-avoiding behaviors. External factors include environmental conditions, time, and resources. Decision-making options are externally limited when time is short or when the environment is characterized by a “we’ve always done it this way” attitude. Values affect all aspects of decision making, from the statement of the problem/issue through the evaluation. Values, determined by one’s cultural, social, and philosophical background, provide the foundation for one’s ethical stance. The steps for engaging in ethical decision making are similar to the steps described earlier; however, alternatives or options identified in the decision-making process are evaluated with the use of ethical resources. Resources that can facilitate ethical decision making include institutional policy; principles such as autonomy, nonmaleficence, beneficence, veracity, paternalism, respect, justice, and fidelity; personal judgment; trusted co-workers; institutional ethics committees; and legal precedent. Certain personality factors, such as self-esteem and self-confidence, affect whether one is willing to take risks in solving problems or making decisions. Keynes (2008) asserts that individuals may be influenced based on social pressures. For example, are you inclined to make decisions to satisfy people to whom you are accountable or from whom you feel social pressure? Characteristics of an effective decision maker include courage, a willingness to take risks, self-awareness, energy, creativity, sensitivity, and flexibility. Ask yourself, “Do I prefer to let others make the decisions? Am I more comfortable in the role of ‘follower’ than leader? If so, why?” Exercise 6-2 Identify a current or past situation that involved resource allocation, end-of-life issues, conflict among healthcare providers or patient/family/significant others, or some other ethical dilemma. Describe how the internal and external factors previously described influenced the decision options, the option selected, and the outcome. Group Decision Making There are two primary criteria for effective decision making. First, the decision must be of a high quality; that is, it achieves the predefined goals, objectives, and outcomes. Second, those who are responsible for its implementation must accept the decision. Higher-quality decisions are more likely to result if groups are involved in the problem-solving and decision-making process. In reality, with the increased focus on quality and safety, decisions cannot be made alone. When individuals are allowed input into the process, they tend to function more productively and the quality of the decision is generally superior. Taking ownership of the process and outcome provides a smoother transition. Multidisciplinary teams should be used in the decision-making process, especially if the issue, options, or outcome involves other disciplines. Research findings suggest that groups are more likely to be effective if members are actively involved, the group is cohesive, communication is encouraged, and members demonstrate some understanding of the group process. In deciding to use the group process for decision making, it is important to consider group size and composition. If the group is too small, a limited number of options will be generated and fewer points of view expressed. Conversely, if the group is too large, it may lack structure, and consensus becomes more difficult. Homogeneous groups may be more compatible; however, heterogeneous groups may be more successful in problem solving. Research has demonstrated that the most productive groups are those that are moderately cohesive. In other words, divergent thinking is useful to create the best decision. For groups to be able to work effectively, the group facilitator or leader should carefully select members on the basis of their knowledge and skills in decision making and problem solving. Individuals who are aggressive, are authoritarian, or manifest self-oriented behaviors tend to decrease the effectiveness of groups. The nurse leader or manager should provide a nonthreatening and positive environment in which group members are encouraged to participate actively. Using tact and diplomacy, the facilitator can control aggressive individuals who tend to monopolize the discussion and can encourage more passive individuals to contribute by asking direct, open-ended questions. Providing positive feedback such as “You raised a good point,” protecting members and their suggestions from attack, and keeping the group focused on the task are strategies that create an environment conducive to problem solving. Advantages of Group Decision Making The advantages of group decision making are numerous. The adage “two heads are better than one” illustrates that when individuals with different knowledge, skills, and resources collaborate to solve a problem or make a decision, the likelihood of a quality outcome is increased. More ideas can be generated by groups than by individuals functioning alone. In addition, when followers are directly involved in this process, they are more apt to accept the decision, because they have an increased sense of ownership or commitment to the decision. Implementing solutions becomes easier when individuals have been actively involved in the decision-making process. Involvement can be enhanced by making information readily available to the appropriate personnel, requesting input, establishing committees and task forces with broad representation, and using group decision-making techniques. The group leader must establish with the participants what decision rule will be followed. Will the group strive to achieve consensus, or will the majority rule? In determining which decision rule to use, the group leader should consider the necessity for quality and acceptance of the decision. Achieving both a high-quality and an acceptable decision is possible, but it requires more involvement and approval from individuals affected by the decision. Groups will be more committed to an idea if it is derived by consensus rather than as an outcome of individual decision making or majority rule. Consensus requires that all participants agree to go along with the decision. Although achieving consensus requires considerable time, it results in both high-quality and high-acceptance decisions and reduces the risk of sabotage. Majority rule can be used to compromise when 100% agreement cannot be achieved. This method saves time, but the solution may only partially achieve the goals of quality and acceptance. In addition, majority rule carries certain risks. First, if the informal group leaders happen to fall in the minority opinion, they may not support the decision of the majority. Certain members may go so far as to build coalitions to gain support for their position and block the majority choice. After all, the majority may represent only 51% of the group. In addition, group members may support the position of the formal leader, although they do not agree with the decision, because they fear reprisal or they wish to obtain the leader’s approval. In general, as the importance of the decision increases, so does the percentage of group members required to approve it. To secure the support of the group, the leader should maintain open communication with those affected by the decision and be honest about the advantages and disadvantages of the decision. The leader should also demonstrate how the advantages outweigh the disadvantages, suggest ways the unwanted outcomes can be minimized, and be available to assist when necessary.

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Why Critical Thinking in Nursing Is Important

8 examples of critical thinking in nursing, improving the quality of patient care, the importance of critical thinking in nursing.

Jul 24, 2024

While not every decision is an immediate life-and-death situation, there are hundreds of decisions nurses must make every day that impact patient care in ways small and large.

“Being able to assess situations and make decisions can lead to life-or-death situations,” said nurse anesthetist Aisha Allen . “Critical thinking is a crucial and essential skill for nurses.”

The National League for Nursing Accreditation Commission (NLNAC) defines critical thinking in nursing this way: “the deliberate nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting, and evaluating information that is both factually and belief-based. This is demonstrated in nursing by clinical judgment, which includes ethical, diagnostic, and therapeutic dimensions and research.”

An eight-year study by Johns Hopkins reports that 10% of deaths in the U.S. are due to medical error — the third-highest cause of death in the country.

“Diagnostic errors, medical mistakes, and the absence of safety nets could result in someone’s death,” wrote Dr. Martin Makary , professor of surgery at Johns Hopkins University School of Medicine.

Everyone makes mistakes — even doctors. Nurses applying critical thinking skills can help reduce errors.

“Question everything,” said pediatric nurse practitioner Ersilia Pompilio RN, MSN, PNP . “Especially doctor’s orders.” Nurses often spend more time with patients than doctors and may notice slight changes in conditions that may not be obvious. Resolving these observations with treatment plans can help lead to better care.

Key Nursing Critical Thinking Skills

Some of the most important critical thinking skills nurses use daily include interpretation, analysis, evaluation, inference, explanation, and self-regulation.

• Interpretation: Understanding the meaning of information or events.
• Analysis: Investigating a course of action based on objective and subjective data.
• Evaluation: Assessing the value of information and its credibility.
• Inference: Making logical deductions about the impact of care decisions.
• Explanation: Translating complicated and often complex medical information to patients and families in a way they can understand to make decisions about patient care.
• Self-Regulation: Avoiding the impact of unconscious bias with cognitive awareness.

These skills are used in conjunction with clinical reasoning. Based on training and experience, nurses use these skills and then have to make decisions affecting care.

It’s the ultimate test of a nurse’s ability to gather reliable data and solve complex problems. However, critical thinking goes beyond just solving problems. Critical thinking incorporates questioning and critiquing solutions to find the most effective one. For example, treating immediate symptoms may temporarily solve a problem, but determining the underlying cause of the symptoms is the key to effective long-term health.

Here are some real-life examples of how nurses apply critical thinking on the job every day, as told by nurses themselves.

Example #1: Patient Assessments

“Doing a thorough assessment on your patient can help you detect that something is wrong, even if you’re not quite sure what it is,” said Shantay Carter , registered nurse and co-founder of Women of Integrity . “When you notice the change, you have to use your critical thinking skills to decide what’s the next step. Critical thinking allows you to provide the best and safest care possible.”

Example #2: First Line of Defense

Often, nurses are the first line of defense for patients.

“One example would be a patient that had an accelerated heart rate,” said nurse educator and adult critical care nurse Dr. Jenna Liphart Rhoads . “As a nurse, it was my job to investigate the cause of the heart rate and implement nursing actions to help decrease the heart rate prior to calling the primary care provider.”

Nurses with poor critical thinking skills may fail to detect a patient in stress or deteriorating condition. This can result in what’s called a “ failure to rescue ,” or FTR, which can lead to adverse conditions following a complication that leads to mortality.

Example #3: Patient Interactions

Nurses are the ones taking initial reports or discussing care with patients.

“We maintain relationships with patients between office visits,” said registered nurse, care coordinator, and ambulatory case manager Amelia Roberts . “So, when there is a concern, we are the first name that comes to mind (and get the call).”

“Several times, a parent called after the child had a high temperature, and the call came in after hours,” Roberts said. “Doing a nursing assessment over the phone is a special skill, yet based on the information gathered related to the child’s behavior (and) fluid intake, there were several recommendations I could make.”

Deciding whether it was OK to wait until the morning, page the primary care doctor, or go to the emergency room to be evaluated takes critical thinking.

Example #4: Using Detective Skills

Nurses have to use acute listening skills to discern what patients are really telling them (or not telling them) and whether they are getting the whole story.

“I once had a 5-year-old patient who came in for asthma exacerbation on repeated occasions into my clinic,” said Pompilio. “The mother swore she was giving her child all her medications, but the asthma just kept getting worse.”

Pompilio asked the parent to keep a medication diary.

“It turned out that after a day or so of medication and alleviation in some symptoms, the mother thought the child was getting better and stopped all medications,” she said.

Example #5: Prioritizing

“Critical thinking is present in almost all aspects of nursing, even those that are not in direct action with the patient,” said Rhoads. “During report, nurses decide which patient to see first based on the information gathered, and from there they must prioritize their actions when in a patient’s room. Nurses must be able to scrutinize which medications can be taken together, and which modality would be best to help a patient move from the bed to the chair.”

A critical thinking skill in prioritization is cognitive stacking. Cognitive stacking helps create smooth workflow management to set priorities and help nurses manage their time. It helps establish routines for care while leaving room within schedules for the unplanned events that will inevitably occur. Even experienced nurses can struggle with juggling today’s significant workload, prioritizing responsibilities, and delegating appropriately.

Example #6: Medication & Care Coordination

Another aspect that often falls to nurses is care coordination. A nurse may be the first to notice that a patient is having an issue with medications.

“Based on a report of illness in a patient who has autoimmune challenges, we might recommend that a dose of medicine that interferes with immune response be held until we communicate with their specialty provider,” said Roberts.

Nurses applying critical skills can also help ease treatment concerns for patients.

“We might recommend a patient who gets infusions come in earlier in the day to get routine labs drawn before the infusion to minimize needle sticks and trauma,” Robert said.

Example #7: Critical Decisions

During the middle of an operation, the anesthesia breathing machine Allen was using malfunctioned.

“I had to critically think about whether or not I could fix this machine or abandon that mode of delivering nursing anesthesia care safely,” she said. “I chose to disconnect my patient from the malfunctioning machine and retrieve tools and medications to resume medication administration so that the surgery could go on.”

Nurses are also called on to do rapid assessments of patient conditions and make split-second decisions in the operating room.

“When blood pressure drops, it is my responsibility to decide which medication and how much medication will fix the issue,” Allen said. “I must work alongside the surgeons and the operating room team to determine the best plan of care for that patient’s surgery.”

“On some days, it seems like you are in the movie ‘The Matrix,’” said Pompilio. “There’s lots of chaos happening around you. Your patient might be decompensating. You have to literally stop time and take yourself out of the situation and make a decision.”

Example #8: Fast & Flexible Decisions

Allen said she thinks electronics are great, but she can remember a time when technology failed her.

“The hospital monitor that gives us vitals stopped correlating with real-time values,” she said. “So I had to rely on basic nursing skills to make sure my patient was safe. (Pulse check, visual assessments, etc.)”

In such cases, there may not be enough time to think through every possible outcome. Critical thinking combined with experience gives nurses the ability to think quickly and make the right decisions.

Nurses who think critically are in a position to significantly increase the quality of patient care and avoid adverse outcomes.

“Critical thinking allows you to ensure patient safety,” said Carter. “It’s essential to being a good nurse.”

Nurses must be able to recognize a change in a patient’s condition, conduct independent interventions, anticipate patients and provider needs, and prioritize. Such actions require critical thinking ability and advanced problem-solving skills.

“Nurses are the eyes and ears for patients, and critical thinking allows us to be their advocates,” said Allen.

Image courtesy of iStock.com/ davidf

Last updated on Jul 24, 2024. Originally published on Aug 25, 2021.

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Thinking your way to successful problem-solving

13 September, 2001 By NT Contributor

VOL: 97, ISSUE: 37, PAGE NO: 36

Jacqueline Wheeler, DMS, MSc, RGN, is a lecturer at Buckinghamshire Chilterns University College

Problems - some people like them, some do not think they have any, while others shy away from them as if they were the plague. Opportunities, in the form of problems, are part of your life.

The most difficult decision is deciding to tackle a problem and implement a solution, especially as it is sometimes easier to ignore its existence. Problem-solving takes time and effort, but once a problem has been addressed the nurse can feel satisfied that the issue has been resolved and is therefore less likely to re-emerge.

Nurses make clinical decisions using two different approaches. The first is the rationalist approach, which involves an analysis of a situation so that subsequent actions are rational, logical and based on knowledge and judgement. The second approach is based on a phenomenological perspective, where a fluid, flexible and dynamic approach to decision-making is required, such as when dealing with an acutely ill patient.

Types of problems

Problems come in different guises and the solver can perceive them either as a challenge or a threat. One of the most common types of problem is when the unexpected happens. As a nurse you plan and implement care for a patient based on your knowledge and experience, only to find that the patient’s reaction is totally different from that expected but without any apparent reason.

Another type of problem is an assignment where others set a goal or task. Throughout your working life you will be required to undertake duties on behalf of other people. For some this is difficult as they feel unable to control their workload. Others see it as an opportunity to develop new skills or take on additional responsibilities. Opportunities can be perceived as problems by those who fear failure.

A third type of problem is when a dilemma arises. This is when it is difficult to choose the best solution to a problem because the nurse is confronted with something that challenges his or her personal and/or professional values.

Diagnosing problems

The sooner a problem is identified and solutions devised, the better for all involved. So try to anticipate or identify problems when they occur through continuously monitoring staff performance and patient outcomes.

Listening to and observing junior staff will help you to detect work or organisational concerns, because when there are problems staff are likely to behave in an unusual or inconsistent manner.

Initial analysis

Remember that people view things differently, so what you perceive as a problem may not be one to anyone else. So before you begin thinking about what to do - whether to keep it under surveillance, contain it or find a solution - you should undertake an initial analysis. This will help you to understand the problem more clearly.

An analysis will also enable you to prioritise its importance in relation to other problems as problems do not occur one at a time.

Routine problems often need little clarification, so an initial analysis is recommended for non-routine problems only. Even then, not all problems justify the same degree of analysis. But where it is appropriate, an initial analysis will provide a basis from which to generate solutions.

Perception is also important when dealing with patients’ problems. For example, if a patient gives up reading because he or she cannot hold the book (objective), the nurse may assume it is because the patient has lost interest (subjective, one’s own view).

Generating solutions

It is essential for the problem-solver to remember that, where possible, solutions must come from those connected with the problem. If it is to be resolved, agreement must be owned by those involved as they are probably the best and only people who can resolve their differences. The manager should never feel that he or she must be on hand to deal with all disputes.

To solve a problem you need to generate solutions. However, the obvious solution may not necessarily be the best. To generate solutions, a mixture of creative and analytical thinking is needed (Bransford, 1993).

Creativity is about escaping from preconceived ideas that block the way to finding an innovative solution to a problem. An effective tool for assisting in this process is the technique of lateral thinking, which is based largely on the work of Edward de Bono, who regards thinking as a skill.

There are several ways to encourage creative decision-making. One method that works best for specific or simple problems is brainstorming. If the ground rules of confidentiality and being non-judgemental are applied, it will produce a free flow of ideas generated without fear of criticism (Rawlinson, 1986).

Time constraints and staff availability may make it difficult for all those involved in a problem to meet. In such cases an adaptation of brainstorming - where a blank piece of paper is given to those involved and each writes down four solutions to the problem - may be the answer. A similar technique is the collective notebook, where people are asked to record their thoughts and ideas about a problem for a specified period.

An alternative is where one person writes down a list of solutions in order of priority, which is then added to by others. This helps to prioritise the ideas generated. All these methods produce data that can then be analysed by the problem-solver.

When the problem affects people in different geographical areas, solutions can be generated by obtaining the opinion of experts through the use of a questionnaire, which is known as the Delphi technique (McKenna, 1994).

When an apparently insurmountable problem presents itself, it is often useful to divide it into smaller pieces. This is known as convergent thinking. Using divergent thinking - where you consider a problem in different ways to expand your view - may also help. 

A final alternative is the stepladder technique, which is time-consuming but effective if the issue is stirring up strong feelings. This requires the people involved in the problem to be organised into groups. First, two people try to solve the problem, then a third member is drawn in, to whom the solution reached by the first two is presented. All three then try to agree a solution. More people are added to the group, if necessary, in a similar way, until there is agreement of all involved. Provided the individuals are motivated to solve the problem, this technique creates ownership and commitment to implementing the agreed solution.

Analytical thinking, which follows a logical process of eliminating ideas, will enable you to narrow the range down to one feasible solution.

Although someone has to make the ultimate decision on which solution to implement, there are advantages to group decision-making: a greater number of possible solutions are generated and conflicts are resolved, resulting in decisions being reached through rational discussion.

This does, however, require the group to be functioning well or the individuals involved may feel inhibited in contributing to the decision-making. One individual may dominate the group or competition between individuals may result in the need to win taking precedence over deciding on an agreed practical solution.

As nursing becomes less bureaucratic individuals are being encouraged to put forward their own ideas, but social pressures to conform may inhibit the group. We do not solve problems and make decisions in isolation, but are influenced by the environment in which we work and the role we fulfil in that environment. If group members lack commitment and/or motivation, they may accept the first solution and pay little attention to other solutions offered.

Making a decision

There are three types of decision-making environments: certain, risk and uncertain. The certain environment, where we have sufficient information to allow us to select the best solution, is the most comfortable within which to make a decision, but it is the least often encountered.

We usually encounter the risk environment, where we lack complete certainty about the outcomes of various courses of action.

Finally, the uncertain environment is the least comfortable within which to make decisions as we are almost forced to do this blind. We are unable to forecast the possible outcomes of alternative courses of action and, therefore, have to rely heavily on creative intuition and the educated guess.

Taking this into consideration, you should not contemplate making a decision until you have all the information needed. Before you make your decision, remind yourself of the objective, reassess the priorities, consider the options and weigh up the strengths, weaknesses, opportunities and threats of each solution.

An alternative is to use the method that Thomas Edison used to solve the problem of the electric light bulb. Simply focus on your problem as you drift off to sleep, and when you wake up your subconscious mind will have presented you with the answer. But bear in mind that this is not a scientific way of solving problems - your subconscious can be unreliable.

If you are not sure about your decision, test the solution out on others who do not own the problem but may have encountered a similar dilemma. Once you have made your choice stick to it, or you may find it difficult to implement because those involved will never be sure which solution is current. They will also be reluctant to become involved in any future decision-making because of your uncertainty.

The next step is to ensure that all the people involved know what decision has been made. Where possible, brief the group and follow this up with written communication to ensure everyone knows what is expected of them. You may need to sell the decision to some, especially if they were not involved in the decision-making process or the solution chosen is not theirs.

Implementing the solution

Finally, to ensure the solution is implemented, check that the people involved know who is to do what, by when and that it has happened. Review the results of implementing your solution (see Box) and praise and thank all those involved.

- Part 1 of this series was published in last week’s issue: Wheeler, J. (2001) How to delegate your way to a better working life. Nursing Times; 97: 36, 34-35.

Next week. Part three: a step-by-step guide to effective report writing.

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Factors Influencing on Problem Solving Ability of Nursing Students Experiencing Simulation Practice

Hyun hee jo.

1 Department of Nursing, Hyejeon College, 19 Daehak 1-gil, Hongseong-eup, Hongseong-gun 32244, Korea

Won Ju Hwang

2 College of Nursing Science, East-West Nursing Research Institute, Kyung Hee University, 26 Kyunghee-Daero, Dongdaemun-gu, Seoul 02447, Korea

Associated Data

The data presented in this study are available on request from the corresponding author.

It has become important for nurses to implement self-leadership and exercise critical thinking in problem-solving to address the health issues of patients. This has led to a need for nursing education programs in which nursing students learn to embrace self-leadership and self-evaluation approaches to develop their skills. Within 260 nursing undergraduates with experience in simulation practice as study subjects, a self-reporting survey was conducted on self-leadership, goal commitment, critical thinking, and problem-solving skills. An analysis was conducted using the SPSS/WIN 21.0 program. t -test and ANOVA were conducted to validate the difference between problem-solving abilities. Multiple regression was conducted to examine the impact of these variables on problem-solving skills. The variables of religion, satisfaction with major, goal commitment, and critical thinking were found to have a significant impact on problem-solving abilities. The results were as follows: critical thinking (β = 0.36, p < 0.05), goal commitment (β = 0.28, p < 0.05), and explanatory power of 41%. To improve the nursing undergraduates’ problem-solving abilities through simulation practice, there needs to be a method that supports them in setting goals with self-leadership and enhance goal commitment. The method also needs to support the development of their critical thinking and curiosity for questions deriving from experiencing diverse programs in order to deliver effective outcomes.

1. Introduction

1.1. background.

In recent nursing environments, complex and strategic practices are required, and the role of nurses is recognized for its importance. In order to effectively respond to the patients’ demands, it has become important for nurses to equip themselves with specialized skills [ 1 , 2 ].

Such change requires nurses to build not only a high level of knowledge and skills, but also self-leadership to actively solve problems with independence and autonomy, as well as critical thinking to set the best goals and to identify strategies and grounds for apply clinical judgment and decision [ 3 , 4 ]. To this effect, nursing education must provide a learning environment that reflects actual practices and supports students to ultimately equip themselves with problem-solving abilities by coming up with their own measures, as well as searching and collecting the required data in order to exercise leadership and make logical and critical decisions in various situations, thereby ultimately carrying out nursing at a technical level [ 5 ]. Problem-solving abilities are an essential quality and the most notable characteristic of nursing professionals, in which they utilize their knowledge, explore and arrange information, and use it to serve the intended purposes under complex and unpredictable circumstances [ 6 ]. However, the traditional top-down education systems have limitations in teaching such practical skills and are inadequate to prepare students for many challenges in the field [ 7 ]. For nursing graduates, attitudes that are active, autonomous, responsible, and such are required in clinical practice, and many of them face difficulties to meet the requirements as they have developed passive and dependent approaches during early school years centered on university entrance exams [ 8 ].

Insufficient training on practice at nursing colleges leads to the decline in clinical practice capability of new nurses after their graduation. To complement this, more universities are adopting a high-performance simulator to enhance their training on practice [ 7 , 9 ]. The training simulators provide benefits by reproducing simulated situations which are similar to actual clinical environments, motivating the learning of students and providing direct learning effects by having students engage in activities in simulated situations. They also provide additional learning effects through post-learning evaluation and a re-design process. Furthermore, it has been reported that such practice-oriented training provides benefits of enhancing students’ critical thinking skills, allowing them to experience the outcomes of their clinical intervention, and to share with other students and reflect on their experience through de-briefing [ 10 ]. In simulated situations, trainees must apply in a critical way the theories learned to address patient issues and set their priorities to make decisions in a self-directed manner [ 11 , 12 ]. If students lack self-leadership, which is underscored in the simulated training on practice, they may not be able to improve problem-solving skills the essential skill required for change [ 13 , 14 ].

Due to the characteristics of nursing training, the result of training is directly related to practice in the field, and this has led to more attention being given to the design of training courses involving skills development and training experience for nurses aiming to develop and promote their critical-thinking and problem-solving abilities [ 15 , 16 ]. However, there is an insufficient number of studies on the relationship between self-leadership, goal commitment, critical thinking, and problem-solving abilities in nursing students. Thereby, the study results may be used as basic data for developing and operating training programs to enhance nursing undergraduates’ problem-solving skills.

1.2. Study Purpose

The purpose of this study was to identify the relationship between self-leadership, goal commitment, critical thinking, and problem-solving abilities in nursing undergraduates who experienced simulation training on practice and the impact of these variables on problem-solving processes. This involved (1) investigating the relationship between self-leadership, goal commitment, critical thinking, and problem-solving abilities; and (2) identifying the impact of self-leadership, goal commitment, and critical thinking on problem-solving abilities.

2. Methodology

2.1. study design.

This is a descriptive investigation study conducted to identify the relationship between self-leadership, goal commitment, critical thinking, and problem-solving abilities of nursing undergraduates with the experience of simulation practice training.

2.2. Sampling Strategy

The participants of this study consisted of nursing undergraduates (juniors and seniors) at 4 universities who received 30 to 60 h of simulated practice training. The training was provided in one of the following two ways; one day of simulated practice training during clinical practice or five-day simulated practice training. All universities were equipped with high-performance simulators and used them in practice training. Though equipment and materials used varied by subject, high-performance simulators and dummies were used for most subjects.

2.3. Ethical Considerations

For the bioethics and safety of study subjects, this study was conducted after deliberation by the Institutional Review Board of University and the approval (No: KHSIRB-14-059(EA)) was obtained. During study period, the guidelines of the IRB were complied with. The description of the study was provided to study subjects and the purpose and methods of the study were explained. The survey was handed out to be filled-out by subjects who agreed to participate and they were informed the data they provided would be used solely for the study’s purpose. Study subjects were provided with a small amount of compensation in appreciation of their participation.

2.4. Study Methods

• (1) Demographics

General characteristics included university, age, grade, religion, personal relationships, academic grades, major satisfaction, leadership training experience, and need for leadership. The age groups were divided into two: subjects of 22 years of age or below and subjects of 23 years of age or above. The personal relationships were classified into average, good, and very good. The major satisfaction was classified into unsatisfactory, average, satisfactory, and highly satisfactory.

• (2) Self-leadership

To measure the self-leadership of nursing undergraduates, RSLQ (Revised Self-Leadership Questionnaire) developed by Houghton and Neck [ 17 ] was used after being modified and complemented by Shin et al. [ 18 ] for Korean participants. It consists of 35 items under 3 main categories and 9 sub-categories. The Cronbach’s α by item ranged from 0.74 to 0.88 and the Cronbach’s α value in this study was between 0.72 and 0.85.

• (3) Goal commitment

To measure the goal commitment of nursing undergraduates, the tool suggested by Klein et al. [ 19 ] was used. The tool consisted of 5 items measured with the 5-point Likert scale. The higher score meant a greater goal commitment. Items 1, 2, and 3 were reverse items. The Cronbach’s α was 0.83 and the value in this study was 0.75.

• (4) Critical thinking disposition

To measure the critical thinking disposition of nursing undergraduates, the tool suggested by Yoon [ 3 ] was used. The tool consisted of a total of 27 items under 7 categories of intellectual eagerness/curiosity, prudence, self-confidence, systematicity, intellectual fairness, healthy skepticism, and objectivity. In the study by Yoon [ 3 ], the Cronbach’s α was 0.84 and the value in this study was 0.74.

• (5) Problem-solving abilities

The Social Problem Solving Inventory-Revised (SPSI-R) modified by D’Zurilla and Maydeu-Olivares [ 20 ] and translated by Choi [ 21 ] were used to measure problem-solving abilities. SPSI-R consisted of two major scales to measure the problem-solving orientation and problem-solving skills, as well as 5 sub-categories of positive problem orientation, negative problem orientation, rational problem-solving, impulsive/careless style, and avoidance coping style. The Cronbach’s α was 0.78 and the value ranged from 0.68 to 0.91 in this study.

2.5. Data Collection Method

The study data were collected from 18 September 2014 to 4 November 2014. The data were collected from juniors and seniors with an experience of simulated practice training from nursing departments at 4 universities in Seoul, and upon agreement for participation. The surveys were then handed out, filled-in, and retrieved straight away. A total of 280 copies were distributed and 276 copies were retrieved. With 16 surveys with insincere responses excluded, a total of 260 copies were used for final analysis.

2.6. Data Analysis

The data collected were analyzed using SPSS/WIN 21.0 program (IBM Corp., Armonk, NY, USA). The variables of mistakes, average, and percentage were used to identify general characteristics. The difference in problem-solving abilities by general characteristic was validated through t -test and ANOVA with additional validation through Scheffe test and Fisher’s exact test. The relationship between the subjects’ self-leadership, goal commitment, critical thinking, and problem-solving abilities was analyzed using Pearson’s correlation coefficient. A multiple regression was used to identify the impact of these variables on problem-solving abilities.

3.1. General Characteristics of Study Participants

The subjects of this study comprised 260 juniors and seniors in the nursing department with the experience of 30 to 60 h of simulated training on practice. The juniors accounted for 72.3% and the good personal relationships accounted for 56.5%. The major satisfaction was 55.4% and no leadership training experience was 61.9%. The results were as follows: self-leadership of 3.59 ± 0.71, goal commitment of 3.68 ± 0.57, critical thinking of 3.57 ± 0.57, and problem-solving abilities of 3.14 ± 0.58 ( Table 1 ).

Mean of Dependent and Independent Variables (N = 260).

M = Mean, SD = Standard Deviation

3.2. Problem-Solving Abilities According to General Characteristics

The difference in problem-solving abilities according to the general characteristics of the study subjects showed significance in grades, personal relationships, academic grades, and major satisfaction. The juniors (2.75 ± 0.62) showed higher numbers of impulsive style (t = 1.30, p = 0.003) than seniors (2.62 ± 0.46) in relation to grades. The seniors showed higher numbers of positive problem orientation (t = −0.55, p = 0.013) and rational problem-solving (t = 0.00, p = 0.039). There were significant differences in positive problem orientation (F = 5.68, p = 0.004) and negative problem orientation (F = 7.96, p < 0.001) in relation to personal relationships. The result of post-validation shows that subjects with “average (3.65 ± 0.53)” personal relationships showed a lower positive problem orientation than subjects with “very good (2.51 ± 0.72)” personal relationships. The subjects with “very good (2.51 ± 0.72)” personal relationships showed a lower negative problem orientation than subjects with “average (3.09 ± 0.66)” and “good (2.97 ± 0.71)” personal relationships. Subjects with higher academic grades showed a lower negative problem orientation (F = 3.77, p = 0.024), impulsive careless style (F = 3.78, p = 0.024), and evasive style (F = 4.65, p = 0.010) than subjects with lower academic grades. There was a significant difference in all sub-categories of problem-solving abilities in relation to major satisfaction. For positive problem orientation (F = 5.35, p < 0.001), subjects with “average (3.62 ± 0.48)” showed lower problem-solving abilities than subjects with “very satisfactory (4.10 ± 0.47)”. For negative problem orientation (F = 6.32, p < 0.001), subjects with “average (3.18 ± 0.68)” showed higher problem-solving abilities than subjects with “satisfactory (2.84 ± 0.69)” and “very satisfactory (2.59 ± 0.76)”. For rational problem solving (F = 5.10, p = 0.001), subjects with “very satisfactory (3.82 ± 0.36)” showed higher problem-solving abilities than subjects with “average (3.43 ± 0.40)” and “unsatisfactory (3.48 ± 0.69)”. For impulsive/careless style (F = 4.24, p = 0.002), subjects with “unsatisfactory (2.95 ± 0.50)” showed higher problem-solving abilities than subjects with “satisfactory (2.65 ± 0.51)” and “very satisfactory (2.45 ± 0.63)”. While there was a significant difference observed in relation to evasive style (F = 2.99 p = 0.019), no difference was observed in the post validation. ( Table 2 )

General Characteristics of Subjects’ Problem-solving Abilities (N = 260).

§ PPO = Positive Problem Orientation, ‖ NPO = Negative Problem Orientation, ¶ RPS Rational Problem Solving, # ICS = Impulsive Careless Style, ** ACS = Avoidance Coping Style, * = Fisher’s exact test. a,b,c = scheffe

3.3. Correlation between Subjects’ Self-Leadership, Goal Commitment, Critical Thinking, and Problem-Solving Abilities

A Pearson’s correlation was used to identify the correlation between general characteristics, self-leadership, goal commitment, critical thinking, and problem-solving abilities of nursing undergraduates with the experience of simulated practice training and the result shows that there was a positive correlation between problem-solving abilities and the variables of critical thinking (r = 0.54, p < 0.01), goal commitment (r = 0.47, p < 0.01), and self-leadership (r = 0.43, p < 0.05). For general characteristics, a positive correlation was observed in major satisfaction (r = 0.29, p < 0.01) and personal relationships (r = 0.21, p < 0.01; Table 3 ).

Correlations Between Problem-solving abilities and Other Variables in Participants (N = 260).

* p < 0.05. 1. Problem Solving Skills, 2. Self-Leadership, 3. Goal Commitment, 4. Critical Thinking, 5. University, 6. Age, 7. Grade, 8. Religion, 9. Interpersonal, 10. Academic Achievement, 11. Major Satisfaction, 12. Leadership Training Experience, 13. Leadership Training Needs.

3.4. Influential Factors on Problem-Solving Abilities of Nursing Undergraduates with the Experience of Simulated Practice Training

To identify the influential factors on the problem-solving abilities of nursing undergraduates with the experience of simulated practice training, the variables that showed significance difference of p < 0.5 in relation to the subjects’ general characteristics were designated as potential influential factors. These variables were self-leadership, goal commitment, critical thinking, age, religion, personal relationships, major satisfaction, and leadership training experience. A multiple regression analysis was conducted and the results were as follows: For the analysis, the general characteristics of the subjects’ age, having or not having a religious belief, having a good or not good personal relationships, and being satisfied or unsatisfied about the major were processed as dummy-coded variables. First, as a result of testing the assumptions of regression analysis, it was found that all of them were satisfied.

Having a religious belief, major satisfaction, goal commitment, and critical thinking were observed to be significant influential factors on problem-solving abilities. The results were as follows: critical thinking (β = 0.36) and goal commitment (β = 0.28). Self-leadership, age, personal relationships, and leadership training experience showed no significance, with the value of p > 0.05. The regression equation used to analyze the influential factors showed the following results: R = 0.65, R 2 = 0.42, modified R 2 = 0.41, F = 23.17, p < 0.01, and Durbin–Watson = 1.97. The Durbin–Watson value was 1.97 and close to 2, ensuring the independence of error, and the explanatory power was 41%. The tolerance limit was 1 or below and the variance inflation factor (VIF) was lower than 10, showing no problem for multi-collinearity ( Table 4 ). Next, as a result of analyzing influence using Cook’s D statistics, there was no more than 1.0 discrete in 260 subjects. Following a result of residual analysis, linearity of the model, normality of the error term, and homoscedasticity were confirmed.

The Influencing Factors on the Problem-Solving Abilities (N = 260).

SE = Standard Error, VIF = Variance Inflation Factor.

4. Discussion

Nursing education and training must provide a learning environment that reflects actual practice and enables students to set up alternative measures to solve learning problems, search and obtain required data, and equip themselves with problem-solving abilities. However, the traditional top-down education systems have limitations in teaching such practical skills and are inadequate to prepare students for many challenges in the field [ 7 ]. This study aimed to analyze the relationship between the self-leadership, goal commitment, critical thinking, and problem-solving abilities of nursing undergraduates with the experience of simulated practice training and to obtain basic data to improve the quality of simulated practice training.

The results of the study are similar to the previous studies; an average mean of 3.14 points for problem-solving skills, 3.36 points for problem-solving orientation, and 2.98 points for problem-solving abilities [ 22 ]. This suggests that nursing undergraduates evaluated their problem-solving abilities to be of intermediate level and perceived themselves as an intermediate-level problem solver. For sub-categories, the positive problem orientation showed the highest point, followed by rational problem-solving and evasive style. This implies that nursing undergraduates showed a comparatively positive emotional state when faced with problems, but had a tendency to evade problems for as long as possible rather than confront them. According to the study by Cha et al. [ 22 ], nursing undergraduates who believed they were ineffective problem-solvers tended to imagine more hardships than there actually were, when faced with problems. To address this problem, the study also stressed out the need for measures to support nursing undergraduates to experience various situations and respond in objective, rational, and cognitive manners. Problem-solving abilities refer to a process of making decisions using effective problem-solving strategies based on one’s knowledge and are regarded as very important skills for professional nurses. A study by Yang [ 23 ] stated that the current nursing education and training courses provide content and methods that are not effective in teaching nursing undergraduates about the understanding or skills of the problem-solving process, and results in many undergraduates experiencing hardships when faced with various challenges in the clinical field. As insufficient training on practice leads to a decline in the clinical practice capability of new nurses after graduation; therefore, various teaching methods should be applied to enhance students’ problem-solving abilities and to enable nursing undergraduates to solve problems in a positive, active, and rational manner.

The difference in problem-solving abilities according to the general characteristics was partially significant for grades, personal relationships, and academic grades. The major satisfaction exhibited significant differences in all sub-categories. For positive problem orientation and rational problem-solving, the subjects with a greater major satisfaction showed a higher level of problem-solving skills. For negative problem orientation and impulsive/careless style, subjects with less major satisfaction showed a higher point. These results are consistent with the results of another study [ 24 ] on critical thinking disposition, problem-solving ability, and clinical competence of nursing students in that the subjects with a lower major satisfaction had lower problem-solving skills. This means that the subjects with a greater major satisfaction had more effective, intellectual, and creative problem-solving abilities than those with less major satisfaction. This is believed to be due to factors such as academic achievement, active attitude toward problem-solving, and such, according to their level of major satisfaction.

The influential factors for problem-solving abilities were goal commitment and critical thinking. Although the general characteristics of age, satisfaction with nursing major, and personal relationships showed correlations with problem-solving skills, no significant result was observed in the regression analysis. In a study by Aubé et al. [ 25 ], a virtual management project was implemented for undergraduates to examine the data provision and goal commitment. The results showed that subjects with a higher goal commitment had a higher problem-solving performance. The study also stated that subjects could develop actual capabilities required in the field only by having a deep understanding of situations and that they could acquire problem-solving abilities required in the field by committing to the situation not as an observer, but as a learner. Therefore, to enhance problem-solving skills, various programs should be developed and implemented to improve students’ goal commitment. In addition, team projects or action-based learning programs should be implemented to promote interactions between different learning programs and enhance students’ commitment to the study. In this way, the programs may enhance the problem-solving abilities of students by motivating them.

According to the study by Han and Park [ 26 ], greater critical thinking leads to higher problem-solving skills, which in turn enhances one’s confidence in problem-solving and improves the problem-solving skills. The study found that nursing undergraduates must develop critical thinking skills in order to explore problems in diverse aspects and seek solutions in a discreet manner. Training using simulators is an effective educational method as it motivates students’ learning and provides direct learning effects through simulated activities. Furthermore, it enhances the students’ critical abilities and allows them to experience the outcomes of their clinical intervention, as well as to share with other students and reflect on their experience through de-briefing [ 10 ].

Tucker et al. [ 27 ] stated that problems can be solved through a regular method based on guidelines and algorithms, and that such guidelines and algorithms are the result of such efforts. To develop problem-solving skills, which is an essential quality for nurses, one must develop a strong goal commitment and critical thinking abilities. To this effect, nursing undergraduates should be subjected to various nursing situations and be able to establish their own goals and commitment. They should also develop an accurate understanding of situations and critical thinking abilities to accurately identify, analyze, consolidate, and utilize data. To this effect, various simulated practice trainings, action-based learning, and problem-solving-oriented teaching programs, which support a natural learning process through a repetitive process, should be implemented to have learners actively engage in learning and develop a sense of commitment as well as critical thinking.

This study suggests that, while self-leadership showed no significant impact on problem-solving skills, it had impact on the problem-solving abilities of nursing undergraduates [ 28 , 29 ]. It was also suggested that self-leadership affected the goal commitment, which impacted the problem-solving abilities and improved it. This was due to the fact that not all nursing undergraduates exercised self-leadership and the level of self-leadership varied according to the individuals’ ability, environmental factors, function, and task structure [ 17 ]. Self-leadership involves a behavior strategy and cognitive strategy. Nursing students need to be committed to this process to solve problems and must put efforts to address problems on their own in order for their problem-solving abilities to develop. To enhance problem-solving skills, they must be committed to achieving their goals. Educational and training programs should be developed and implemented to provide nursing students with circumstances in which they are able to exercise self-leadership and in which they are encouraged to develop self-leadership skills.

This study holds significance in that it suggests the need for the development and implementation of various programs involving simulated practice training to enhance the problem-solving abilities of nursing undergraduates. It also suggests the need for measures to make students set their own goals and improve the level of their goal commitment, as well as the fact that the use of self-leadership may enhance the effectiveness of the process. Furthermore, it suggests the possible synergetic effects on developing critical thinking abilities by allowing students to build critical curiosity over questions they face by experiencing various programs. On the other hand, this study had limitations in that the scope of sample was limited to nursing undergraduates with the experience of simulated practice training at certain universities in Seoul city who agreed to participate in the study, suggesting that the study results should not be used for generalization. In addition, there are limitations to defining the correlation in that a cross-sectional study method was used in which the cause and outcome variables of the collected data were measured at the same time point for analysis.

5. Conclusions

This study was conducted to identify the relationship between the self-leadership, goal commitment, critical thinking, and problem-solving abilities of nursing undergraduates with the experience of simulated practice training. The multiple regression analysis results show that the variables of goal commitment and critical thinking had a significant impact on the nursing undergraduates’ problem-solving abilities (F = 23.17, p < 0.01), with the explanatory power of 41%. In order to enhance the problem-solving abilities of nursing undergraduates, various education programs which involve discussions with simulated training on practice to demonstrate a step-by-step approach to problematic situations, an establishment of hypothesis, and team cooperation must be developed and implemented [ 30 , 31 , 32 ]. At this stage, measures are required to encourage students to set up their own goals and enhance goal commitment; the effectiveness is expected to increase if the process involves self-leadership. In addition, there may be synergetic effects from students participating in various programs, through training and classes, and developing questions and critical thinking as well as curiosity. Based on the study results, the following suggestions are made. There is a need for repetitive studies on nursing undergraduates and professional nurses under various circumstances and on self-leadership, which was explained as a parameter for problem-solving skills. In addition, a comprehensive program must be developed in which simulated practice training involves not only enhancing the learners’ problem-solving abilities and critical thinking, but also developing self-leadership and goal commitment.

Funding Statement

This research was supported by Basic Science Research Program through the National Research Foundation of Korea funded by the Ministry of Science, ICT & Future Planning (No. 2017R1A2B4008496). It was also funded by the Korea Health Industry Development Institute (KHIDI) through the Ministry of Health & Welfare, Republic of Korea (grant number: HI18C1317). The funding agencies had no role in the study design, the collection, analysis, or interpretation of data, the writing of the report, or the decision to submit the article for publication (PI: WJ Hwang).

Author Contributions

(1) H.H.J.: Study conception and design, data collection, data analysis, and interpretation, and writing the manuscript. (2) W.J.H.: Study conception and design, development of design, drafting of the article, supervision, and writing of the manuscript. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

For the bioethics and safety of study subjects, this study was conducted after deliberation by the Institutional Review Board of Kyung Hee University and the approval (No: KHSIRB-14-059(EA)) was obtained.

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Home » Degrees » RN to MSN » Registered Nurse to Master of Science in Nursing in Administrative Leadership in Nursing » How Leaders Approach Problem-Solving

How Leaders Approach Problem-Solving

• Published On: July 12, 2022

No environment is free from problems. But, some require more creative solutions than others.

Healthcare, in particular, presents almost unlimited opportunities for things to go wrong — both in terms of patient care and inter-staff/intra-staff relationships. The problems present within healthcare settings are often a matter of life and death.

It takes effective leadership to keep all issues to a minimum and patient safety remains a priority.

What Makes a Great Leader?

If we think about the great leaders throughout time, they share a few common characteristics. Specific to nurse leaders, Indeed.com lists the following as core qualities for leaders:

• compassion/empathy
• critical thinking
• dedication to excellence
• communication
• collaboration/team building
• open-mindedness
• forward-thinking
• accessibility

Another valuable quality in leadership is being proactive in problem-solving. Good leaders handle issues as they arrive. They are capable of “putting out fires,” and that’s important. Yet, great leaders anticipate problems before they come to a head.

Core Skills Nurse Leaders Need to Possess

While some of the above resonates as more intuitive, emotional intelligence — as opposed to procedural — can be learned. Of course, there are practical skills nurse leaders need to develop as well.

Examples of these skills are healthcare finance and economics. Mastering budgets and efficiently allocating resources is important for nurse leaders. Nurses also need to know how to communicate financial demands to upper administration.

The online Registered Nurse (RN) to Master of Science in Nursing (MSN) in Administrative Leadership program from Northeastern State University (NSU) dedicates a course to heightening nurses’ skills and knowledge surrounding this responsibility.

NSU’s program also includes a course titled Organizational and Systems Management in Nursing. The course description states that nurses will learn about “contemporary influences, theories, principles, and functional strategies related to management/administration and organizational systems at the micro, meso, and macrosystem levels.”

Leadership’s Role in Addressing Lateral and Horizontal Violence (LHV)

While nurse leaders don’t necessarily need to be experts in human resources, it’s a substantial knowledge base. Human resources knowledge is especially relevant given the persistence of lateral and horizontal violence (LHV) within the nursing profession. The World Health Organization (WHO), International Council of Nurses and Public Services International have recognized this issue as a significant global public health priority.

Just how dangerous is LHV to nursing? A study published by Nurse Management describes LHV as: “all acts of meanness, hostility, disruption, discourtesy, backbiting, divisiveness, criticism, lack of unison, verbal or mental abuse, and scapegoating. [These] behaviors taint healthcare organizations; cause irreparable harm to workplace culture; breakdown team communication; and severely impact the quality of the care provided, thereby jeopardizing patient safety.”

With a solid leadership foundation, nurses can handle toxic behaviors that damage the work environment. In doing so, they change the workplace culture and guiding others to follow in their footsteps.

Empowerment Sets Everyone Up for Success

Perhaps the greatest responsibility of a nurse leader is to empower those in their charge. John Quincy Adams said, “If your actions inspire others to dream more, learn more, do more and become more, you are a leader.”

Northeastern State University recognizes empowerment as an essential skill. In the Leadership Development for the Advanced Nursing Professional course, students learn to “effectively manage change, empower others, and influence political processes.”

What Type of Leader Do You Aspire to Be?

It takes much more than “putting in your time” to become an effective leader. Nurses might rise through the ranks based on experience, but are they actually effecting change in the nursing profession? Unless they possess a robust leadership skill set, the answer is likely no. So, what kind of leader do you want to be?

Learn more about Northeastern State University’s online RN to MSN in Administrative Leadership program .

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Problem-Solving and Communication Skills of Undergraduate Nursing Students

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Background:

Problem-solving and effective communication are essential skills for daily nursing duties. Despite several studies highlighting those concepts, few examined the relationship between these concepts among nursing students. This study aimed to investigate undergraduate nursing students' problem-solving and communication skills.

A cross-sectional correlational design was used. A sizeable convenient sample of 489 undergraduate nursing students was recruited from six nursing schools in Jordan. Data were collected using an online self-administered survey. The Arabic version of the Problem-Solving Inventory and a translated version of the Communication Skills Attitude Scale were used. Descriptive statistics and multiple linear regression were used to analyze the data.

The sample included 64.4% females. The mean total score of the problem-solving scale was 96.63 (SD=16.99). Gender, considering self as an initiative person, and negative attitude toward communication were significant negative predictors, while positive attitude toward communication was a positive predictor of nursing students' problem-solving skills.

Implications:

Educational programs that improve nursing students' attitudes toward communication and mental health courses that focus on positive personality traits are needed to improve nursing students' problem-solving skills.

Conclusion:

The results indicated a moderate level of problem-solving skills, a high level of positive attitudes toward communication skills, and a low level of negative attitudes toward communication skills among undergraduate nursing students.

1. INTRODUCTION

Nurses work in a highly complex and unpredictable environment, where they face changes in patients' needs and work circumstances. They must retain adequate problem-solving abilities to determine the most suitable resolutions to the stressful situations they experience through their day-to-day work [ 1 , 2 ]. Problem-solving is a critical part of the nursing daily working duties. When encountering a problem, nurses have to apply their intellectual and cognitive abilities to examine and recognize the situation and construct a proposed solution supported by evidence [ 3 , 4 ].

Problem-solving proficiency is an intellectual and behavioral process requiring an advanced level of questioning that can help the nurse analyze the situation, suggest the most suitable solution, and apply it to solve the problem [ 5 ]. Therefore, problem-solving abilities are necessary for formatting, performing, and assessing nursing care [ 6 ], and this expertise can be boosted by academic education [ 7 ]. Education is the continuous development of individual and professional competency that prepares individuals to face daily life needs. This entails that the individuals be inspired and capable of constructing operative resolutions to their problems. Nursing students should learn to appraise the situations they encounter critically and apply nursing knowledge and skills to solve emerging problems effectively [ 8 ]. Problem-based learning (PBL) in nursing is a method of learning that enhances nursing students' abilities to utilize nursing theories in clinical practice through active involvement, problem-solving, and critical thinking. It requires nursing learners to use their knowledge and skills in new situations to achieve their goals [ 9 ].

Nursing students' acquisition of problem-solving skills is impeded by many factors, such as gender, personality traits, and the opportunities to practice problem-solving skills [ 10 - 12 ]. It is essential to exercise problem-solving by gathering information and producing knowledge regarding the problems [ 4 ]. Therefore, nursing students must identify the significance of communication skills and obtain sufficient capabilities in communication during their education process [ 4 ]. Communication is the process of information generating and exchanging between two or more individuals, which is crucial for nurses to provide high-quality and safe healthcare services to patients. Moreover, communication skills are essential to empower nurses to present their knowledge and exhibit it in practice [ 13 ]. Previous studies indicated that good communication skills are linked to nursing students' problem-solving abilities [ 1 , 14 ].

Studying problem-solving and communication skills among nursing students will provide an attempt to offer a better understanding of both problem-solving abilities and communication skills, which will provide an opportunity to enhance nursing education. Although some studies investigated the relationship between nursing students' communication skills and problem-solving skills, this relationship has not been adequately addressed [ 14 ]. Therefore, this study aimed (1) to determine the problem-solving abilities and communication skills of undergraduate nursing students and (2) to identify predictors of the problem-solving skills of undergraduate nursing students.

2.1. Design

A cross-sectional correlational design was used.

2.2. Sample and Sampling

The target population in this study was undergraduate nursing students enrolled in the nursing program. The number of nursing students in Jordan in 2020 -2021 was 8983 [ 15 ]. The sample size was calculated using Raosoft (sample size calculator), with a margin error of 5% and a confidence level of 95%. The minimum required sample size was 368 nursing students. A convenient sampling technique was used to recruit nursing students from six nursing schools in Jordan from April 2021 to September 2021. The inclusion criteria included students enrolled in the nursing program from all academic years.

2.3. Study Procedure

Data were collected using an online self-administered survey. Google forms were used to create the online survey. Target universities' websites and social media groups were used to provide the questionnaire link for the target population. Networking and snowballing techniques were used to include students. Further, the contact details of the researchers were provided to participants in case they had any questions.

2.4. Ethical Considerations

Ethical approval was obtained from the Scientific and Research Committee at the Faculty of Nursing, Al-Ahliyya Amman University. Also, permissions from the tool developers were obtained before data collection started. Students who agreed to participate in the study were asked to check the consent statement before starting the survey. The participation was voluntary, and students were informed that they had the right to withdraw from the study without any consequences.

2.5. Measures

Socio-demographic variables included ten questions about age, gender, marital status, academic year, previous hospital clinical experience for bridging students, initiative, and previous hospital training.

2.5.1. Problem-solving

The Arabic version of the Problem-Solving Inventory (PSI) was used to measure problem-solving skills [ 16 ]. It is a Likert-type self-assessment questionnaire consisting of 35 items (3 filler items) measuring the individual's self-perception regarding his/her problem-solving skills. The PSI consists of three subscales: Problem-Solving Confidence (PSC), Approach-Avoidance Style (AAS), and Personal Control (PC). The PSC subscale (11 items) assesses self-confidence and belief in the ability to solve problems effectively ( e.g. , “I make decisions and I am happy with them later.”). The AAS subscale (16 items) assesses approaching versus avoiding problems ( e.g. , “Even though I work on a problem, sometimes I feel like I am groping or wondering, and I am not getting down to the real issue.”). The PC subscale (5 items) assesses the degree of self-control ( e.g. , “I have a systematic method for comparing alternatives and making decisions.”). The PSI is scored using a 6-point Likert scale ranging from strongly agree (1) to strongly disagree (6). The possible PSI score range is from 32 to 192. Low scores on the PSI reflect a positive self-appraisal of problem-solving abilities. The Arabic version showed an excellent internal consistency level of .89 [ 16 ].

2.5.2. Communication Skills

The Communication Skills Attitude Scale (CSAS) was used to collect students’ attitudes about communication skills learning developed by Rees, Sheard, and Davies [ 17 ]. The scale consists of two subscales: The Positive Attitude Scale (PAS) and the Negative Attitude Scale (NAS). Each subscale has 13 items using a 5-point Likert scale ranging from 'strongly agree' (1) to 'strongly disagree' (5). The possible scores for each subscale range from 13 to 65. Higher scores of the subscale indicate stronger positive or negative attitudes toward communication skills. The English version of the CSAS was translated into Arabic by two independent bilingual nursing professors. Both professors were fluent in both Arabic and English. Then, the CSAS was back-translated into English by another professor specializing in translation. The translated version was evaluated by four nursing experts who have experience in tool translation and validation. The goal of the translation process was to produce an Arabic version of the CSAS with items that were equivalent in meaning to the original English version [ 18 ].

2.6. Data Analysis

Statistical Package for Social Science (SPSS) version 21 was used to analyze the data [ 19 ]. Descriptive statistics, including percentages, mean, and standard deviation, were calculated to describe demographics, including age, gender, marital status, and other defining characteristics of the students. In addition, range, mean and standard deviation were calculated for the PSI and its three subscales, the PAS and the NAS subscales. Two-step multiple linear regression was used to identify predictors of problem-solving skills. All assumptions of this analysis were met, and multicollinearity was tested. Alpha level was set at 0.05.

3.1. Sample Characteristics

A total sample of 489 nursing students participated in the study. The students' average age was 22 years (SD=3.76) and ranged from 18 to 43. The sample included 64.4% females. Most of the sample (83.6%) considered themselves initiative persons. Of the study sample, 71.6% received training in a hospital see Table 1 .

3.2. Problem Solving and Communication Skills

The mean score for the problem-solving scale was 96.63 (SD=16.99). PSC subscale mean score was 31.87 (SD=9.54), the PC subscale mean score was 17.21 (SD=3.66), and the AAS subscale mean score was 47.54 (SD=8.98). The PAS subscale mean score was 50.71 (SD=11.49), and the NAS subscale mean score was 35.06 (SD=9.26) (Table 2 ).

3.3. Predictors of Nursing Students' Problem-Solving Skills

Two-step multiple hierarchal linear regression was generated to assess predictors of nursing students' problem-solving skills, controlling for selected demographics (Table 3 ). The analysis showed that model 1, which included age, gender, and marital status as covariates, was significant (F = 4.36, p = 0.005) and explained 2% (R2 = .020) of the variance in problem-solving skills. In this model, gender was a significant negative predictor (p =.018), meaning male nursing students are expected to have significantly less problem-solving skills than female nursing students. In model 2, the covariates (academic year, previous clinical experience in hospitals, considering yourself an initiative person, previous training in the hospital during the nursing study, PAS, and NAS) were entered into the model. With these covariates, the model remained significant (F = 47.934, p < .001). The model explained 46.4% (R2 = .464) of the variance in problem-solving skills. In the second model, considering yourself an initiative person and PAS were significant negative predictors, while NAS positively predicted nursing students' problem-solving skills. The effect of gender in the second model attenuated and became insignificant.

4. DISCUSSION

This study investigated predictors of problem-solving skills of undergraduate nursing students. A cross-sectional correlational design was used on a large convenient sample of 489 undergraduate nursing students from six nursing schools in Jordan. The results showed that nursing students have a moderate level of problem-solving skills. They reported high positive and low negative attitudes toward communication skills. Male nursing students and students with negative attitudes toward communication skills have significantly lower problem-solving skills. Nursing students who consider themselves initiative and who have positive attitudes toward communication skills have significantly higher problem-solving skills.

The levels of problem-solving skills in this study were consistent with prior studies in Turkey [ 4 , 20 ]. Another study conducted in Korea and included a convenience sample of 161 nursing students found that the total mean score for PSI was 119.23. Compared to the current study, nursing students in Jordan reported higher problem-solving skills [ 21 ]. A study conducted in Turkey examined the critical thinking and problem-solving skills of 93 nursing students. The study found that the mean total score of PSI was 87. 55(SD=2.65) and 86.32(SD=2.50) in two groups of nursing students [ 22 ]. In addition, a study conducted in Iran that included 322 undergraduate nursing students found that the mean score of PSI was 89.52 (SD=21.58) [ 23 ]. Compared to the current study, nursing students in Jordan reported lower problem-solving skills.

Nursing students in the current study reported high positive and low negative attitudes toward communication skills. Another study was conducted in Turkey included 170 nurses and 413 students studying at the nursing school. The study found that both groups had moderately good communication [ 24 ]. Another study conducted with 246 nursing students in Turkey found that nursing students reported moderate communication skills of 77.325(SD=11.33) [ 4 ]. A Finnish study was conducted to examine the effect of a pilot communication skills course on second-year medical students. Using the same tool as in this study, Koponen, Pyörälä & Isotalus [ 25 ] found that the median PAS and NAS scores before the course were 45 and 31, respectively. In another study in Spain, PAS and NAS mean scores were examined in a group of first-year medical and nursing students. The results showed that PAS and NAS mean scores were 51.43 and 23.05, respectively [ 26 ]. Compared to these results, nursing students in the current study had a comparable PAS mean score; however, these students had higher negative attitudes toward communication skills.

The female gender predicted better problem-solving skills than the male gender. On the contrary, Koc et al . [ 20 ] found that the problem-solving skills of male students were higher than those of female students, while no significant differences were found based on gender in other studies [ 4 , 21 , 23 ]. The finding that female students showed better problem-solving skills might be explained in a cultural context as women in the Arab culture face several challenges in the workplace. Despite the higher enrollment rates of females in Jordanian universities, the male-dominant community demands females to make further efforts in their tasks to prove themselves [ 27 , 28 ]. Nursing students who considered themselves to be initiative reported better problem-solving skills as being initiative is a personality trait that facilitates creative problem-solving [ 29 ]. In this study, positive attitudes toward communication predicted higher problem-solving abilities, while negative attitudes toward communication predicted lower problem-solving abilities of nursing students. Kim and Sim [ 1 ] found that communication skills significantly affected problem-solving skills among clinical nurses. In addition, communication skills enhance nurses' understanding of patients' conditions and their perception of professionalism. Another study that included undergraduate nursing students also found that good communication skills improve students' problem-solving abilities [ 14 ].

4.1. Study Limitations

This study is not without limitations. First, the instruments used in this study were online self-administered questionnaires. Second, the cross-sectional design limited the investigation of causal relationships between study variables. Further research studies are needed to understand better how nursing students improve their problem-solving skills.

4.2. Implications

Several studies examined undergraduate nursing students' problem-solving and communication skills, but few were in Jordan. This was one of the very few studies that examined important concepts for nursing practice in Jordan. Developing communication and problem-solving skills in nursing students is an investment for the profession's future. The findings indicated the need for developing educational programs that improve nursing students' attitudes toward communication. In addition, the study showed an essential effect of a personality trait on problem-solving skills among nursing students. Implementing mental health courses that focus on positive personality traits is one of the approaches that can enhance nursing students' problem-solving skills.

The results indicated a moderate level of problem-solving skills, a high level of positive attitudes toward communication skills, and a low level of negative attitudes toward communication skills. Male gender and having higher negative attitudes toward communication skills were significant predictors of lower problem-solving skills while being an initiative having positive attitudes toward communication skills were significant predictors of higher problem-solving skills.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

The ethical approval was obtained from the Scientific and Research Committee at the Faculty of Nursing, Al-Ahliyya Amman University.

HUMAN AND ANIMAL RIGHTS

No animals were used in this research. All procedures performed in studies involving human participants were in accordance with the ethical standards of institutional and/or research committee and with the 1975 Declaration of Helsinki, as revised in 2013.

CONSENT FOR PUBLICATION

Informed consent was obtained from all participants.

STANDARDS OF REPORTING

STROBE guidelines were followed.

AVAILABILITY OF DATA AND MATERIALS

The details are available within the article.

CONFLICT OF INTEREST

The authors declare no conflict of interest financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

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Problem solving in nursing practice: application, process, skill acquisition and measurement

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• 1 King's College, University of London, England.
• PMID: 8320382
• DOI: 10.1046/j.1365-2648.1993.18060886.x

This paper analyses the role of problem solving in nursing practice including the process, acquisition and measurement of problem-solving skills. It is argued that while problem-solving ability is acknowledged as critical if today's nurse practitioner is to maintain effective clinical practice, to date it retains a marginal place in nurse education curricula. Further, it has attracted limited empirical study. Such an omission, it is argued, requires urgent redress if the nursing profession is to meet effectively the challenges of the next decade and beyond.

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